Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Global, egional, and na ional le els and causes o ma e nal mo ali y du ing 1990–2013: a sys ema ic analysis o he Global Bu den o Disease S udy 2013 A ull lis o au ho s and a ilia ions appea s a he end o he a icle. Summa y Backg ound—The i h Millennium De elopmen Goal (MDG 5) es ablished he goal o a 75% educ ion in he ma e nal mo ali y a io (MMR; numbe o ma e nal dea hs pe 100 000 li ebi hs) be ween 1990 and 2015. We aimed o measu e le els and ack ends in ma e nal mo ali y, he key causes con ibu ing o ma e nal dea h, and iming o ma e nal dea h wi h espec o deli e y. Me hods—We used obus s a is ical me hods including he Cause o Dea h Ensemble model (CODEm) o analyse a da abase o da a o 7065 si e-yea s and es ima e he numbe o ma e nal dea hs om all causes in 188 coun ies be ween 1990 and 2013. We es ima ed he numbe o p egnancy- ela ed dea hs caused by HIV on he basis o a sys ema ic e iew o he ela i e isk o dying du ing p egnancy o HIV-posi i e women compa ed wi h HIV-nega i e women. We also es ima ed he ac ion o hese dea hs agg a a ed by p egnancy on he basis o a sys ema ic e iew. To es ima e he numbe s o ma e nal dea hs due o nine di e en causes, we iden i ied 61 *Co espondence o: D Nicholas J Kassebaum, Ins i u e o Heal h Me ics and E alua ion, Uni e si y o Washing on, 2301 Fi h A enue, Sui e 600, Sea le, WA 98121, USA, [email p o ec ed]. †Au ho s lis ed alphabe ically ‡Join senio au ho s Con ibu o s NJK and CJLM p epa ed he i s d a . NJK, CS, ADL, CJLM, and RL inalised he d a on he basis o commen s om o he au ho s and e iewe eedback. NJK, ADL, CJLM, and RL concei ed he s udy and p o ided o e all guidance. NJK comple ed all modelling. NJK, AB-V, and MSC did he s a is ical analysis o model esul s. All o he au ho s p o ided da a, de eloped models, e iewed esul s, ini ia ed modelling in as uc u e, and e iewed he epo . See Online o appendix Decla a ion o in e es s Cy us Coope has ecei ed consul ancy ees, lec u e ees, and hono a ia om Amgen, GlaxoSmi hKline, Alliance o Be e Bone Heal h, Me ck Sha p and Dohme, Eli Lilly, P ize , No a is, Se ie , Med onic, and Roche. Ka he ine B Gibney ecei ed he Na ional Heal h and Medical Resea ch Council Gus a Nossal schola ship sponso ed by CSL in 2012; his awa d is pee - e iewed h ough he s anda d Na ional Heal h and Medical Resea ch Coun il pee - e iew p ocess, and CSL does no play any pa in selec ion o he awa dee. No i o Kawakami has ecei ed ees om Meiji, O suka, EAP Consul ing, Fuji su So wa e Technologies, Japan P oduc i i y Cen e , Occupa ional Heal h Founda ion, Japan Housing Finance Agency, Aishin-Seiki, and he Japan Den al Associa ion; consul ancy ees om Sekisui Chemicals, Junpukai Heal h Ca e Cen e , and Osaka Chambe o Comme ce and Indus y; and oyal ies om Igaku-Shoin, Taisha-kan, Nanko-do, Nanzan-do, PHP Publica ion, and Fuji su So wa e Technologies. No i o Kawakami has also ecei ed esea ch g an s om he Japanese Minis y o Educa ion, Science, and Technology; he Japanese Minis y o Heal h, Labo and Wel a e; Fuji su So wa e Technologies; So bank; and Japan Managemen Associa ion. Guilhe me V Polanczyk has ecei ed g an s o esea ch suppo om he Na ional Council o Scien i ic and Technological De elopmen , he São Paulo Resea ch Founda ion, and he Uni e si y o São Paulo; has se ed as a paid consul an o Shi e; has se ed on he speake s’ bu eau o Shi e; and has ecei ed oyal ies om Edi o a Manole. Jas inde A Singh has ecei ed esea ch g an s om Takeda and Sa ien ; has ecei ed consul an ees om Sa ien , Takeda, Regene on, and Alle gan; is a membe o he execu i e o OMERACT, an o ganisa ion ha de elops ou come measu es in heuma ology and ecei es a ms-leng h unding om 36 companies; is a membe o he Ame ican College o Rheuma ology’s Guidelines Subcommi ee o he Quali y o Ca e Commi ee; and is a membe o he Ve e ans A ai s Rheuma ology Field Ad iso y Commi ee. The o he au ho s decla e no compe ing in e es s. Eu ope PMC Funde s G oup Au ho Manusc ip Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Published in inal edi ed o m as: Lance . 2014 Sep embe 13; 384(9947): 980–1004. doi:10.1016/S0140-6736(14)60696-6. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s sou ces om a sys ema ic e iew and 943 si e-yea s o i al egis a ion da a. We also did a sys ema ic e iew o epo s abou he iming o ma e nal dea h, iden i ying 142 sou ces o use in ou analysis. We de eloped es ima es o each coun y o 1990–2013 using Bayesian me a- eg ession. We es ima ed 95% unce ain y in e als (UIs) o all alues. Findings—292 982 (95% UI 261 017–327 792) ma e nal dea hs occu ed in 2013, compa ed wi h 376 034 (343 483–407 574) in 1990. The global annual a e o change in he MMR was −0·3% (−1·1 o 0·6) om 1990 o 2003, and −2·7% (−3·9 o −1·5) om 2003 o 2013, wi h e idence o con inued accele a ion. MMRs educed consis en ly in sou h, eas , and sou heas Asia be ween 1990 and 2013, bu ma e nal dea hs inc eased in much o sub-Saha an A ica du ing he 1990s. 2070 (1290–2866) ma e nal dea hs we e ela ed o HIV in 2013, 0·4% (0·2–0·6) o he global o al. MMR was highes in he oldes age g oups in bo h 1990 and 2013. In 2013, mos dea hs occu ed in apa um o pos pa um. Causes a ied by egion and be ween 1990 and 2013. We eco ded subs an ial a ia ion in he MMR by coun y in 2013, om 956·8 (685·1–1262·8) in Sou h Sudan o 2·4 (1·6–3·6) in Iceland. In e p e a ion—Global a es o change sugges ha only 16 coun ies will achie e he MDG 5 a ge by 2015. Accele a ed educ ions since he Millennium Decla a ion in 2000 coincide wi h inc eased de elopmen assis ance o ma e nal, newbo n, and child heal h. Se ing o a ge s and associa ed in e en ions o a e 2015 will need ca e ul conside a ion o egions ha a e making slow p og ess, such as wes and cen al A ica. Funding—Bill & Melinda Ga es Founda ion. In oduc ion Since he 1980s, he global heal h communi y has ocused on educing ma e nal mo ali y h ough a sequence o ini ia i es, beginning wi h he Sa e Mo he hood mo emen in 1987, o he c ea ion o he Pa ne ship o Ma e nal, Newbo n and Child Heal h in 2005.1,2 The p io i y acco ded o educ ions in ma e nal mo ali y is shown by i s choice as one o he eigh Millennium De elopmen Goals (MDGs). Despi e hese e o s and isibili y, he e was b oad conce n ha li le o no p og ess was being made, which p omp ed in ensi ied e o s by he UN Sec e a y Gene al h ough he launch o E e y Woman E e y Child in 2010, and he subsequen c ea ion o he Commission on In o ma ion and Accoun abili y o Women’s and Child en’s Heal h.2,3 In 2010, a comp ehensi e assessmen o global ends in ma e nal mo ali y sugges ed ha he ma e nal mo ali y a io (MMR; numbe o ma e nal dea hs pe 100 000 li ebi hs) had dec eased by 1·3% pe yea since 1990.4 Subsequen e isions o he his o ical es ima es ha e shown e en la ge wo ldwide a es o change, om −1·9% o −3·1% pe yea .5,6 This e idence collec i ely sugges s ha , al hough conce ns abou he a e o change o ma e nal mo ali y migh ha e been oo pessimis ic, he e is subs an ial unce ain y abou how apid he dec ease has been and abou he ac ual numbe s o dea hs in se e al la ge popula ions. I policy deba es abou accele a ion o ma e nal mo ali y educ ions a e o be use ully in o med, goals es ablished, and a ge s se o ep oduc i e heal h, up- o-da e moni o ing o he le els and ends in ma e nal mo ali y is essen ial.7 Kassebaum e al. Page 2 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Compa ed wi h child mo ali y, ma e nal mo ali y has been mo e di icul o ack o e ime a he na ional le el.8 Se e al majo challenges ha e o be add essed in any measu emen e o : misclassi ica ion o ma e nal dea hs o o he causes in coun ies wi h comple e i al egis a ion and medical ce i ica ion o causes o dea h; subs an ial sampling e o in measu emen s ha depend on su ey ecall because ew ma e nal dea hs a e epo ed; la ge non-sampling e o in su ey and census measu emen s as demons a ed in se ings wi h epea ed o e lapping measu emen s; a ia ion in he demog aphic assessmen o ep oduc i e-age mo ali y om all causes, pa icula ly in he 1990s; and he need o models o syn hesise da a om se e al s udies o gene a e es ima es when da a a e spa se.9-11 The subs an ial di e ences be ween global modelling e o s, which a e a imes subs an ial, emphasise he in luence o each o he analy ical s eps used o es ima e ma e nal mo ali y.12 Poli ical a en ion o how coun ies a e p og essing owa ds MDG 5 a ge s is in ensi ying.1,13 Dono s, global heal h pa ne s, and na ional p og amme manage s a e unde s andably us a ed by he wide unce ain y in e als and he a iabili y o es ima es om di e en analys s.8 He e, we use he sys ema ic app oach o he Global Bu den o Diseases, Inju ies, and Risk Fac o s S udy 2013 (GBD 2013) o measu e le els and ack ends in ma e nal mo ali y, he key causes con ibu ing o ma e nal dea h, and he iming o ma e nal dea hs. In GBD 2013, wi h applica ion o igo ous s a is ical me hods o c i ically app aise and syn hesise da a om di e en sou ces o es ima e le els and causes o dea h in each age and sex g oup, a consis en and holis ic app oach o he challenges o ma e nal mo ali y measu emen is used ha enables compa isons ac oss ime, coun y, and o he impo an causes o dea h in women o ep oduc i e age. Algo i hms o cause o dea h eclassi ica ion a e applied consis en ly ac oss all causes and modelling s a egies use me hods wi h clea ly quan i ied ou -o -sample p edic i e alidi y.14 On he basis o ecen ends in MMR, we also p ojec an MMR scena io o 2030 o in o m policy deba es by iden i ying which coun ies a e in g ea es need o in ensi ied ocus. Me hods Ma e nal mo ali y 1990–2013 Da a—We used he GBD 2013 cause o dea h da abase, which ex ends om 1980 o 2013, o es ima e ma e nal mo ali y. Al hough we epo es ima es o he MDG pe iod 1990– 2013, da a o 1980–90 a e included in he analysis o imp o e he obus ness o he ime end es ima ion. Nagha i and colleagues15 p o ide subs an ial de ail abou he inclusion c i e ia and da a p ocessing o s udies ac oss all causes. B ie ly, building on p e ious analyses, we iden i ied da a om 180 o 188 GBD coun ies, including 4877 si e-yea s o i al egis a ion da a, 1213 si e-yea s o sibling his o ies om Demog aphic and Heal h Su eys (DHS) and Rep oduc i e Heal h Su eys (RHS) p o iding in o ma ion abou he p egnancy- ela ed ac ion o ep oduc i e-age dea hs, 73 si e-yea s o censuses, 626 si e- yea s o ma e nal mo ali y su eillance, and 267 si e-yea s o e bal au opsy analyses co e ing women o ep oduc i e age.4,5,16 We iden i ied he abo e da a sou ces h ough a sys ema ic e iew (appendix), om analyses by Lozano and colleagues5 and GBD 2010 Kassebaum e al. Page 3 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s analyses,16 sea ches o Minis y o Heal h websi es, and a sea ch o he Global Heal h Da a Exchange. The e has been much deba e abou which dea hs o women o ep oduc i e age should be included as ma e nal dea hs. To be classi ied as ma e nal, p egnancy needs o be a causal ac o in dea h. I can ei he ha e a di ec e ec (complica ions o he p egnancy o childbi h, o pos pa um complica ions) o indi ec e ec (exace ba ion o a p e-exis ing condi ion). The e o e, acciden al o inciden al dea hs in which p egnancy had no causal ole a e no classi ied as ma e nal dea hs. De ini ions o na ional use based on he In e na ional Classi ica ion o Diseases (ICD) ha e di e ed om o he ecommenda ions o in e na ional compa isons o he MMR. All de ini ions include di ec and indi ec causes du ing p egnancy and wi hin 6 weeks o he e mina ion o p egnancy ( igu e 1). ICD-10 de ini ions also include la e ma e nal dea hs be ween 6 weeks and 1 yea a e e mina ion.6,17 Fo some causes, such as suicide, he e is na ional a ia ion in whe he hey a e coded as inciden al o indi ec .18,19 MDG guidance o c oss-coun y compa isons o MMR ecommends ha all HIV- ela ed dea hs du ing p egnancy o wi hin 6 weeks should be included in he MMR,20 bu he UN g oup es ima ing ma e nal mo ali y uses only 50% o hese dea hs in hei es ima ion.6,20 Concep ually, only he ac ion o dea hs agg a a ed by p egnancy should be included, because ha is he de ini ion o an indi ec cause o ma e nal mo ali y. We included di ec and indi ec dea hs du ing p egnancy and wi hin 6 weeks o deli e y, plus la e ma e nal dea hs up o 1 yea a e deli e y and he ac ion o HIV- ela ed dea hs agg a a ed by p egnancy. La e ma e nal dea hs we e no coded in ICD-9 so da a a e only a ailable o ICD-10 (ie, om 1994). Addi ionally, because ma e nal dea hs in he age g oup 10–14 yea s ha e been consis en ly epo ed in ou da a sou ces, we ha e es ima ed he numbe o ma e nal dea hs in his age g oup bu ha e no included hem in he compu a ion o he MMR because no s anda d es ima es o bi h a es a e a ailable o his g oup. In i al egis a ion and e bal au opsy da a, ma e nal dea hs a e o en misclassi ied as dea hs a ibu able o o he unde lying causes. We eassigned dea hs assigned o causes ha a e unlikely o be unde lying causes o dea h wi h s anda dised algo i hms.14 The causes o dea h ha a e pa ly eassigned o ma e nal causes a e shown in he appendix.15 We eanalysed DHS and RHS mic oda a o sibling dea hs ha we e ela ed o p egnancy by yea using Gakidou-King weigh s o deal wi h po en ial su i o bias.21 We used a Bayesian noise educ ion algo i hm o p ep ocess da a o a oid he issue o la ge s ochas ic luc ua ions and ze o coun s leading o dis o ed ime ends (appendix). When di e en DHS su eys p o ided da a o ep oduc i e-age dea hs and he numbe ha we e ela ed o p egnancy o he same yea , we pooled esul s o ha yea o educe s ochas ic measu emen e o . Addi ionally, o some i al egis a ion da a, no ma e nal dea hs a e epo ed in speci ic age g oup o o a speci ic pe iod. Noise educ ion algo i hms again help o educe upwa d bias because all ze o coun s would o he wise be d opped om na u al loga i hm dea h a e and logi cause ac ion models. Da a we e una ailable o only eigh coun ies, o which we elied en i ely on model p edic ions o ma e nal mo ali y es ima es. Kassebaum e al. Page 4 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s HIV- ela ed mo ali y—Because o he apid inc ease in ep oduc i e-age mo ali y due o he HIV epidemic in eas e n and sou he n A ica, disen angling he ac ion o HIV dea hs du ing p egnancy ha a e inciden al (ie, no ela ed o p egnancy) om hose agg a a ed by p egnancy (ie, ma e nal dea hs) is impo an . Assessmen o HIV- ela ed mo ali y du ing p egnancy has wo s eps: es ima ion o he ac ion o dea hs du ing p egnancy o wi hin 6 weeks o deli e y ha a e ela ed o HIV, and es ima ion o he ac ion o hese HIV- ela ed dea hs ha a e agg a a ed by p egnancy. Fo he i s s ep, we upda ed Cal e and Ronsmans’ sys ema ic e iew22 (appendix). We iden i ied one new s udy, gi ing a o al o 21 o which we could examine mo ali y isk du ing p egnancy o HIV-posi i e e sus HIV-nega i e women.23-43 We excluded da a om non- ep esen a i e popula ions, om sou ces ha did no include pos pa um dea hs, and any dea hs mo e han 1 yea a e deli e y. Mos s udies did no speci y an i e o i al he apy (ART) s a us. We unde ook a De Simonian-Lai d me a-analysis o he ela i e isk (RR) o dea h. S udies we e he e ogeneous and he pooled RR was 6·40 ( igu e 2). We iden i ied no clea geog aphical pa e n o explain why some s udies a e signi ican ly abo e o below he pooled es ima e, no any clea ela ion wi h o he s udy a ibu es, meaning ha we had an insu icien basis o u he weigh ing o inpu s udies. We used he RR and es ima ed HIV p e alence in p egnan women (based on he UNAIDS Spec um model) o es ima e he popula ion a ibu able ac ion o p egnancy- ela ed dea hs ha a e ela ed o HIV. To es ima e he ac ion o HIV- ela ed dea hs agg a a ed by p egnancy, we did ano he sys ema ic e iew (appendix). We could iden i y only wo s udies o in o m his ac ion, wi h a pooled RR o 1·13 (95% UI 0·73–1·77),44,45 co esponding o a equency o all HIV- ela ed dea hs du ing p egnancy ha should be coun ed as ma e nal dea hs o 11·5% (0–43·5). Se e al addi ional s udies did no show inc eased isk o HIV- ela ed mo ali y du ing p egnancy, bu we e excluded because s a i ica ion o he s udy popula ion on he basis o s age o HIV o ART s a us was no comple ed. Modelling—Following Lozano and colleagues’ me hods,5 we used he Cause o Dea h Ensemble model (CODEm) o model ma e nal mo ali y by age (appendix). Wi h CODEm, many models a e de eloped and hei pe o mance is assessed objec i ely.46 We selec ed nine co a ia es o CODEm o es on he basis o p e iously epo ed associa ions ha also ha e a plausible causal associa ion wi h ma e nal mo ali y: age-speci ic e ili y a e, o al e ili y a e, age-s anda dised HIV dea h a e o emale indi iduals aged 15–49 yea s, neona al dea h a e, lag-dis ibu ed g oss domes ic p oduc (GDP) pe pe son (GDP pe pe son compu ed wi h a iangle lag ha weigh s mo e ecen yea s mo e hea ily), p opo ion o deli e ies occu ing in acili ies, p opo ion o deli e ies o e seen by skilled bi h a endan s, co e age o ou isi s o an ena al ca e, and malnu i ion in child en younge han 5 yea s (<2 SD below mean weigh o age; used as a p oxy o adul nu i ional s a us; appendix). We di ided co a ia es in o h ee g oups o enable compu a ion. Le el 1 co a ia es had he s onges likely ela ion wi h ma e nal mo ali y; co a ia es in le els 2 and 3 had weake likely ela ions. CODEm es s all combina ions o le el 1 co a ia es and nea ly e e y combina ion o le el 2 and le el 3 co a ia es using ou amilies o models: mixed e ec s linea eg ession o he logi - ans o med cause-speci ic mo ali y ac ion, spa ial- empo al Kassebaum e al. Page 5 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Gaussian P ocess Reg ession (ST-GPR) o he logi - ans o med cause-speci ic mo ali y a e, mixed e ec s linea eg ession o he na u al log o he ma e nal dea h a e, and ST- GPR o he na u al log o he ma e nal dea h a e.46 30% o he da a we e no included in he models. Models we e e ained when he be a o each co a ia e was signi ican and in he di ec ion allowed by p e ious e idence. The pe o mance o each e ained model was hen assessed wi h hal he held-ou da a in e ms o he oo -mean squa ed e o o he p edic ion o he model compa ed wi h he da a held ou , and he oo -mean squa ed e o o he end in he model compa ed wi h he end in he da a. Ensemble models we e de eloped on he basis o he ankings o indi idual models and he pe o mance o di e en ensembles assessed in he second hal o he da a held ou o he eg ession (appendix). The bes pe o ming ensemble was selec ed and e i ed o all da a. One o he s eng hs o he GBD is ha all causes a e simul aneously es ima ed. Es ima es o e e y cause-speci ic dea h a e a e necessa y o sum o all-cause mo ali y using he CoDCo ec algo i hm.16 To ensu e hey do sum o all-cause mo ali y, a he le el o each d aw om he pos e io dis ibu ion o each cause o dea h o a speci ic coun y, yea , and age g oup, he sum o all causes was escaled o equal a d aw aken om he unce ain y dis ibu ion o all-cause mo ali y o ha coun y, yea , and age g oup. Causes o ma e nal dea h We disagg ega ed ma e nal dea hs in o nine causes: ma e nal haemo hage, ma e nal sepsis and o he p egnancy- ela ed in ec ions, hype ensi e diso de s o p egnancy, obs uc ed labou , abo ion, o he di ec ma e nal diso de s, indi ec ma e nal diso de s, HIV, and la e ma e nal dea hs. To es ima e he di e en causes o ma e nal dea h, we comple ed a sys ema ic e iew (appendix) o iden i y da a o in o m which p opo ion o o al ma e nal dea hs is due o each cause. Addi ionally, we inco po a ed all i al egis a ion and sample egis a ion da a ha p o ided ICD-coded de ail o ma e nal causes (appendix). We iden i ied 61 s udies and, a e p ocessing, included 943 si e-yea s o i al egis a ion, sample egis a ion, and ma e nal mo ali y su eillance da a. We modelled he p opo ion o ma e nal dea hs o all causes excep HIV using DisMod-MR ( e sion 2.0), which is a Bayesian me a- eg ession ool de eloped o he GBD (appendix). This e sion o DisMod-MR allows o wo ypes o ixed e ec s (s udy a ibu es and coun y co a ia es) and includes nes ed andom e ec s o supe - egion, egion, and coun y. A key ad an age o DisMod-MR is ha i can handle da a epo ed o any age in e al. P edic ions om DisMod-MR o each g oup di ided by coun y, yea , and age a e based on he coun y co a ia es, e e ence alues o he s udy le el co a ia es, and hie a chical andom e ec s. Poin es ima es wi h unce ain y we e p oduced o six disc e e poin s: 1990, 1995, 2000, 2005, 2010, and 2013. Each cause was modelled independen ly. P edic ed cause ac ions o each g oup we e escaled o equal 100% o he dea hs no ela ed o HIV. The escaled cause ac ions we e hen mul iplied by he numbe o ma e nal dea hs in each g oup (di ided by coun y, yea , and age) o ob ain he numbe o dea hs o each ma e nal cause, a sum o which he HIV dea hs we e added. The inal esul includes cause ac ion and numbe o ma e nal dea hs due o each cause, coun y, age g oup, and yea . Kassebaum e al. Page 6 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Timing o ma e nal dea hs An impo an issue o planning o in e en ions is an unde s anding o he iming o ma e nal dea hs wi h espec o labou and deli e y.47 We comple ed a sys ema ic e iew o iden i y s udies o he iming o ma e nal dea hs (appendix). We iden i ied 142 s udies and used i al egis a ion, sample egis a ion, and su eillance da a o la e ma e nal dea h. Many s udies combined he i s 24 h pos pa um (immedia e o ea ly pos pa um) wi h he in apa um pe iod, because e en s o he immedia e pos pa um pe iod a e clinically ela ed o e en s occu ing du ing labou and deli e y. The e o e, we also combined in apa um and immedia e pos pa um pe iods. We ollowed his o ma o cons uc a da ase ha included ou di e en ime windows: dea hs occu ing an epa um (be o e onse o labou ), dea hs occu ing in apa um o du ing he immedia e pos pa um pe iod (up o 24 h a e deli e y), dea hs occu ing du ing he subacu e and delayed pos pa um pe iods (24 h o 42 days a e deli e y),47 and la e ma e nal dea hs (43 days o 1 yea a e deli e y). We modelled he p opo ion o ma e nal dea hs in each o he ou pe iods wi h DisMod-MR ( e sion 2.0). The p edic ed p opo ions we e scaled o 100% o each g oup. 2030 scena io and a e-o -change calcula ions We de eloped a s aigh o wa d o ecas scena io o he MMR o e e y coun y in 2030 by using he es ima ed annualised a e o change om 2003 o 2013 o p edic he MMR o 2030. Fo coun ies wi h an inc easing MMR in ha pe iod, we assumed ha he MMR would emain cons an . We used UN Popula ion Di ision o ecas s o he popula ion aged 15–49 yea s and bi hs o o ecas he numbe o ma e nal dea hs o each coun y. We calcula ed annualised a e o change o 1990–2013 using he con inuous a e-o -change o mula. Achie emen o he MDG 5 a ge would be equi alen o a sus ained 5·5% dec ease pe yea om 1990 o 2015. Unce ain y We epo 95% unce ain y in e als (UIs) o ma e nal dea hs, he MMR, causes o ma e nal dea h, iming o ma e nal dea hs, and annualised a es o change. The ensemble models o ma e nal mo ali y gene a e 1000 d aws om he pos e io dis ibu ion; he alidi y o he UIs was con i med h ough 50 i e a ions o c oss- alida ion wi h da a held ou du ing CODEm es ima ion. Addi ionally, DisMod-MR p oduced 1000 d aws om he pos e io dis ibu ion o he cause analysis and ime-o -dea h analysis. We assumed unce ain y in he es ima ed ac ion o ma e nal dea hs due o each cause o he es ima ed ac ion o ma e nal dea hs in di e en imings o be independen o he unce ain y in he occu ence o ma e nal mo ali y. We calcula ed unce ain y wi h 1000 d aws om he pos e io dis ibu ion o e e y s ep o he es ima ion p ocess, which allows o quan i ica ion and p opaga ion o unce ain y associa ed wi h each o he epidemiological a iables in he GBD amewo k. These UIs a e di e en om con idence in e als, which would only quan i y sampling unce ain y in he unde lying da a o a speci ic model. Kassebaum e al. Page 7 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Role o he unding sou ce The unde o he s udy had no ole in s udy design, da a collec ion, da a analysis, da a in e p e a ion, o w i ing o he epo . The au ho s had access o he da a in he s udy and had inal esponsibili y o he decision o submi o publica ion. Resul s The o al annual numbe o ma e nal dea hs dec eased om 376 034 (95% UI 343 483–407 574) in 1990, o 292 982 (261 017–327 792) in 2013 ( igu e 3A, able 1). The educ ion accele a ed s eadily om 1990 o 2013 ( igu e 3B), wi h co esponding dec eases in MMR ( able 1). Be ween 2003 and 2013, he annual a e o change in MMR was g ea e han −1%, eaching −3·3% o 2012–13 ( igu e 3B). MMR was highes in he oldes age g oups and lowes in women aged 20–29 yea s in bo h 1990 and 2013 ( igu e 4). Howe e , i dec eased signi ican ly be ween 1990 and 2013 o almos all age g oups ( igu e 4). We used da a o he p opo ions o bi hs in di e en ma e nal age g oups and calcula ed ha 9·5% o ma e nal dea hs a e in he g oup aged 15– 19 yea s, 43·1% in women aged 20–29 yea s, and 47·0% in hose aged 30 yea s and olde , wi h he emainde occu ing in he g oup aged 10–14 yea s. Despi e much highe a es o mo ali y in olde age g oups, he o al numbe o dea hs is oughly equal be o e and a e he age o 30 yea s. The MMR in mo he s aged 15–19 yea s in 2013 was 1·5 imes highe han ha in women aged 20–24 yea s, and 1·4 imes highe han in hose aged 25–29 yea s. In 2013, he MMR was 9·5 imes highe o a woman aged 45–49 yea s (1374·4, 95% UI 1117·1–1694·9) han o a woman aged 20–24 yea s (144·1, 120·6–169·9). We eco ded subs an ial di e ences ac oss he GBD egions in he ends in ma e nal dea hs and he MMR ( igu e 5). O he egions whe e he MMR was mo e han 300 in 1990, sou h Asia made he g ea es p og ess by 2013 ( igu e 5A, able 1). In eas e n and wes e n sub- Saha an A ica, MMRs inc eased un il 2005, bu ha e since educed subs an ially ( igu e 5A). The MMR in eas e n sub-Saha an A ica has been changing a a a e o −4·5% pe yea (95% UI −6·0 o −2·8) since 2005. O egions ha had MMRs o 100–300 in 1990, sou heas Asia has had he mos no able dec eases ( igu e 5B). The MMR in he Ca ibbean has ollowed a simila end o eas e n and wes e n sub-Saha an A ica—ie, inc easing o 2005, be o e alling—and i has imp o ed only sligh ly in no h A ica and he Middle Eas ( igu e 5B). The MMR in sou he n sub-Saha an A ica inc eased g ea ly be ween 1990 and 2006, ising om 150·8 (95% UI 115·9–182·6) o 565·7 (420·1–737·2), bu hen ell o 279·8 (202·6–381·5) in 2013 ( igu e 5B). We eco ded dec eases in MMRs in all egions ha had an MMR o 30–100 in 1990 ( igu e 5C, able 1). This educ ion is pa icula ly e iden in eas Asia ( igu e 5C, able 1). The a es o change in sou he n La in Ame ica and cen al La in Ame ica since 2000 seem o ha e been slowe han hose be o e 2000 ( igu e 5C). In egions wi h low MMR in 1990 (<30), he MMR has con inued o educe slowly, excep o in he high-income egion o No h Ame ica ( igu e 5D, able 1). Kassebaum e al. Page 8 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Excep o la e ma e nal dea hs and HIV- ela ed dea hs, he absolu e numbe s o dea hs due o e e y cause dec eased signi ican ly (p<0·001) om 1990 o 2013 ( able 2, appendix). Howe e , in sub-Saha an A ica, he numbe o dea hs due o all causes inc eased om 1990 o 2013 ( able 1). Globally, he bigges absolu e educ ion was in dea hs due o ma e nal haemo hage: om 71 295 (95% UI 64 562–78 329) in 1990, o 44 190 (38 273–50 819) in 2013. The bigges pe cen age dec ease was in ma e nal sepsis, which caused 11·6% (11·4– 11·8) o all ma e nal dea hs in 1990, bu 9·7% (9·5–9·9) in 2013 ( igu e 6A). The p opo ion o ma e nal dea hs due o indi ec causes inc eased sligh ly om 9·1% (95% UI 8·9–9·4) in 1990, o 10·2% (10·0–10·5) in 2013 ( igu e 6A). Addi ionally, he p opo ion o ma e nal dea hs due o o he di ec causes ose om 16·5% (95% UI 16·3–16·8) in 1990, o 17·0% (16·7–17·3) in 2013 ( igu e 6A). The numbe o la e ma e nal dea hs dec eased globally by 3·0%, om 44 814 (95% UI 36 414–53 106) in 1990, o 43 507 (35 667–52 395) dea hs in 2013. In 2013, HIV accoun ed o 1·5% (0·9–2·0) o all ma e nal dea hs in sub-Saha an A ica, bu only 0·4% (0·2–0·6) wo ldwide. The numbe o abo ion- ela ed dea hs dec eased signi ican ly a he global le el (p=0·002; igu e 6A) and in all egions o he han Oceania, whe e no signi ican change occu ed (p=0·35), and sub-Saha an A ica, whe e he numbe o dea hs inc eased signi ican ly a e abo ion (p<0·001). Cause pa e ns a y by egions. The wo mos impo an causes o ma e nal dea h in high- income egions in 2013 we e indi ec and o he di ec causes ( igu e 6B), owing la gely o a dec ease in abo ion- ela ed dea hs, which was he mos impo an cause o ma e nal mo ali y in high-income egions in 1990. The numbe o dea hs due o haemo hage, hype ension, and ma e nal sepsis ha e also dec eased signi ican ly, whe eas he numbe s o dea hs due o indi ec and la e ma e nal causes ha e inc eased since 1990 ( igu e 6B, appendix). By con as , he mos impo an causes in low-income coun ies—o he di ec , abo ion, and haemo hage—ha e no changed be ween 1990 and 2013, al hough di e en ends a e appa en in di e en egions. Fo example, eas Asia had signi ican dec eases in all causes excep HIV (which was es ima ed o be he cause o 0·003% o all ma e nal dea hs in 2013; appendix). The o al global numbe o HIV- ela ed ma e nal dea hs in 2013 was 2070 (95% UI 1290–2866), educed om a peak o 3280 (2041–4403) in 2004. The inc ease in p opo ion o dea hs due o indi ec ma e nal causes was mos no able in La in Ame ica and he Ca ibbean, whe e he p opo ion inc eased om 9·2% (95% UI 8·8–9·8) in 1990, o 11·5% (10·9–12·2) in 2013. In 2013, on a e age, nea ly a qua e o dea hs occu ed an epa um (24·6%, 24·1–25·2), a qua e in apa um and immedia ely pos pa um (27·7%, 27·1–28·2), a hi d subacu e and delayed pos pa um (35·6%, 34·9–36·2), and 12·1% (11·9–12·5) la e. The bigges absolu e change was in in apa um dea hs ( able 2, appendix), which dec eased by mo e han 35%, bu equally no able was ha despi e a dec ease in he mean ac ion o pos pa um dea hs, he p opo ion o o al dea hs occu ing pos pa um and la e ac ually inc eased a he global le el (p<0·001). In 2013, 16 coun ies had MMRs o be ween 500 and 1000: A ghanis an, Came oon, Cen al A ican Republic, Chad, Cô e d’I oi e, Djibou i, E i ea, Guinea, Guinea-Bissau, Libe ia, Leso ho, Mau i ania, Papua New Guinea, Sie a Leone, Sou h Sudan, and Zimbabwe ( igu e 7, able 1). 15 coun ies had MMRs o less han 5: Ando a, Aus alia, Aus ia, Denma k, Kassebaum e al. Page 9 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Bo ja del Pozo-C uz†, Kebede De ibe†, Muluken Dessalegn†, Gab ielle A deVebe †, Sama h D Dha ma a ne†, Uğu Dilmen†, E ic L Ding†, Rob E Do ing on†, Tim R D iscoll†, Se gei Pe o ich E mako †, Ali eza Es eghama i†, Eme i o Jose A Fa aon†, Fa shad Fa zad a †, Manuela Mendonca Felicio†, Seyed-Mohammad Fe esh ehnejad†, G aça Ma ia Fe ei a de Lima†, Mohammad H Fo ouzan a †, Elisabe h B F ança†, Lynne Ga ikin†, Ke e an Gambashidze†, Fo uné Gbè oho Gankpé†, Ana C Ga cia†, Johanna M Geleijnse†, Ka he ine B Gibney†, Mau ice Gi oud†, Elizabe h L Glase †, Ke e an Goginash ili†, Philimon Gona†, Dino ah González-Cas ell†, A sushi Go o†, Hebe N Gouda†, Ha ish Chande Gugnani†, Rahul Gup a†, Rajee Gup a†, Nima Ha ezi-Nejad†, Randah Ribhi Hamadeh†, Mouhanad Hammami†, G aeme J Hankey†, Hilda L Ha b†, Rasmus Ha moelle †, Simon I Hay†, Ileana B He edia Pi†, Hans W Hoek†, H Dean Hosgood†, Damian G Hoy†, Abdulla i Husseini†, Bula T Id iso †, Kai e Innos†, Manami Inoue†, Ka h yn H Jacobsen†, Eiman Jahangi †, Sun Ha Jee†, Paul N Jensen†, Vi ekanand Jha†, Guohong Jiang†, Jos B Jonas†, Knud Juel†, Edmond Ka o Kabagambe†, Haidong Kan†, Nadim E Ka am†, And é Ka ch†, Co ine Kakizi Ka ema†, Anil Kaul†, No i o Kawakami†, Kons an in Kazanjan†, Dh u S Kazi†, And ew H Kemp†, And e Pascal Kengne†, Maia Ke eselidze†, Youse Saleh Khade †, Shams Eldin Ali Hassan Khali a†, Ejaz Ahmed Khan†, Young-Ho Khang†, Luke Knibbs†, Yoshihi o Kokubo†, Soewa a Kosen†, Ba helemy Kua e De o†, Chanda Kulka ni†, Veena S Kulka ni†, G Anil Kuma †, Kaushalend a Kuma †, Ra i B Kuma †, Gene Kwan†, Taa i Lai†, Ra ilal Lalloo†, Hil on Lam†, Van C Lansingh†, Ande s La sson†, Jong-Tae Lee†, James Leigh†, Mall Leinsalu†, Ricky Leung†, Xiaohong Li†, Yichong Li†, Yongmei Li†, Juan Liang†, Xiao eng Liang†, S ephen S Lim†, Hsien-Ho Lin†, S e en E Lipshul z†, Shiwei Liu†, Yang Liu†, Belinda K Lloyd†, S ephanie J London†, Paulo A Lo u o†, Jixiang Ma†, S e an Ma†, Vasco Manuel Ped o Machado†, Nana Kwaku Mainoo†, Ma ek Majdan†, Ch is ophe Chabila Mapoma†, Wagne Ma cenes†, Mel in Ba ien os Ma zan†, Amanda J Mason-Jones†, Man Mohan Mehndi a a†, Fabiola Mejia-Rod iguez†, Ziad A Memish†, Wal e Mendoza†, Ted R Mille †, Edwa d J Mills†, Ali H Mokdad†, Glen Liddell Mola†, Lo enzo Monas a†, Jona han de la C uz Monis†, Julio Cesa Mon añez He nandez†, Ami R Moo e†, Mazia Mo adi-Lakeh†, Rin a o Mo i†, Ul ich O Muelle †, Mi su u Mukaigawa a†, Aliya Naheed†, Ko in S Naidoo†, De ina Nand†, Vinay Nangia†, Denis Nash†, Chakib Nejja i†, Robe G Nelson†, Sudan P asad Neupane†, Cha les R New on†, Ma ie Ng†, Ma k J Nieuwenhuijsen†, Muhammad Im an Nisa †, Sand a Nol e†, Ole F No heim†, Luke Nyaka ahuka†, In-Hwan Oh†, Takayoshi Ohkubo†, Bolajoko O Olusanya†, Saad B Ome †, John Nelson Opio†, O ish Ebe e O isakwe†, Jeya aj D Pandian†, Ch is ina Papach is ou†, Jae-Hyun Pa k†, Angel J Pa e nina Caicedo†, Sco B Pa en†, Vinod K Paul†, Bo is Igo Pa lin†, Neil Pea ce†, Da id M Pe ei a†, Kon ad Pesudo s†, Max Pe zold†, Dan Poena u†, Guilhe me V Polanczyk†, Suzanne Polinde †, Dan Pope†, Fa shad Pou malek†, Dima Qa o†, D Alex Quis be g†, Anwa Ra ay†, Kazem Rahimi†, Va a Rahimi-Mo agha †, Sajjad u Rahman†, Mu ugesan Raju†, Saleem M Rana†, Amany Re aa †, Luca Ron ani†, Nobhoji Roy†, Tania Geo gina Sánchez Pimien a†, Mohammad Ali Sah aian†, Joshua A Salomon†, Uchechukwu Sampson†, I ama S San os†, Monika Sawhney†, Kassebaum e al. Page 16 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Felix Sayinzoga†, Ione J C Schneide †, Aus in Schumache †, Da id C Schwebel†, So aya Seeda †, Sada G Sepanlou†, Edson E Se an-Mo i†, Ma ina Shakh- Naza o a†, Sa a Sheikhbahaei†, Kenji Shibuya†, Hwashin Hyun Shin†, I y Shiue†, Inga Do a Sig usdo i †, Donald H Silbe be g†, And ea P Sil a†, Jas inde A Singh†, Vega d Ski bekk†, Ka en Sliwa†, Se gey S Soshniko †, Luciano A Sposa o†, Chand ashekha T S ee ama eddy†, Kons an inos S oumpoulis†, Lela S u ua†, B yan L Sykes†, Ka en M Tabb†, Robe o Tchio Talongwa†, Feng Tan†, Ca olina Ma ia Teixei a†, E ic Yeboah Tenko ang†, Abdullah Sulieman Te kawi†, And ew L Tho ne-Lyman†, Da id L Ti schwell†, Je ey A Towbin†, Bach X T an†, Mil iadis Tsilimba is†, Uche S Uchendu†, Kingsley N Ukwaja†, Edua do A Undu aga†, Selen Begüm Uzun†, And ew J Vallely†, Coen H an Gool†, Tommi J Vasanka i†, Monica S Va ilala†, N Venke asub amanian†, Sal ado Villalpando†, F ancesco S Violan e†, Vasiliy Vic o o ich Vlasso †, Theo Vos†, S ephen Walle †, Haidong Wang†, Linhong Wang†, XiaoRong Wang†, Yanping Wang†, Sco Weichen hal†, Elisabe e Weide pass†, Robe G Wein aub†, Ronny Wes e man†, James D Wilkinson†, Solomon Mese e Woldeyohannes†, John Q Wong†, Muluemebe Abe a Wo do a†, Gelin Xu†, Yang C Yang†, Yuichi o Yano†, Gokalp Kad i Yen u †, Paul Yip†, Naohi o Yonemo o†, Seok-Jun Yoon†, Mus a a Z Younis†, Chuanhua Yu†, Kim Yun Jin†, Maysaa El SayedZaki†, Yong Zhao†, Ying eng Zheng†, Maigeng Zhou†, Jun Zhu†, Xiao Nong Zou†, Alan D Lopez‡, Mohsen Nagha i‡, Ch is ophe J L Mu ay‡, and Ra ael Lozano‡ (N J Kassebaum MD, A Be ozzi-Villa BA, M S Coggeshall BA, K A Shackel o d BA, C S eine MPH, K R Heu on BS, D Gonzalez-Medina BA, R Ba be BS, C Huynh BA, D Dicke BS, T Templin BA, T M Wolock BA, P o L Dandona PhD, M H Fo ouzan a MD, S S Lim PhD, P o A H Mokdad PhD, M Mo adi-Lakeh MD, M Ng MD, A Schumache BS, P o T Vos PhD, H Wang PhD, M Nagha i PhD, P o C J L Mu ay PhD, P o R Lozano MD), Depa men o Neu ology (D L Ti schwell MD), Pedia ic Anes hesiology and Pain Medicine, Sea le Child en’s Hospi al, School o Medicine (N J Kassebaum), Uni e si y o Washing on, Sea le, WA, USA (R Al onso-C is ancho PhD, P N Jensen MPH, D A Quis be g PhD, M S Va ilala MD); Hace epe Uni e si y Ins i u e o Popula ion S udies, Anka a, Tu key (A Abbasoglu Ozgo en MA, A Ca lin PhD); Facul y o Medicine, Cai o Uni e si y, Cai o, Egyp (P o F Abd-Allah MD); School o Public Heal h, College o Heal h Sciences, Mekelle Uni e si y, Mekelle, Tig ay, E hiopia (S F Abe a MSc); Uni e si y College London, London, UK (P o I Abubaka PhD); Minis y o Heal h, Gabo one, Bo swana (T Achoki PhD); Public Heal h P omo ion Alliance, Osogbp, Nige ia (A Adelekan PhD); Cen e o In e na ional Child Heal h (S M Colquhoun PhD), Uni e si y o Melbou ne, Melbou ne, VIC, Aus alia (Z Ademi PhD, J D Blo e PhD, R G Wein aub MB, P o A D Lopez PhD); Associa ion I oi ienne Pou Le Bien E e Familial, Abidjan, Cô e d’I oi e (A K Adou MD); Uni e si y o Ex emadu a, Cáce es, Spain (P o J C Adsua PhD); Ins i u ion o Public Heal h Sciences, S ockholm, Sweden (E E Aga dh PhD); Make e e Uni e si y, Kampala, Uganda (D Akena PhD, L Nyaka ahuka MPH); Minis y o Heal h, Musca , Oman (D Alas oo MSc, M J Al Kahbou i PhD); Deb e Ma kos Uni e si y, Deb e Ma kos, Amha a, E hiopia (Z A Kassebaum e al. Page 17 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Alemu MPH); Na ional Gua d Heal h A ai s, Riyadh, Saudi A abia (S Alhabib PhD); Uni e si y o Ox o d, Ox o d, UK (R Ali MSc, P o S I Hay DPhil, K Rahimi DM); School o Public Heal h, Uni e si y o Lo aine, Nancy, F ance (P o F Alla PhD); Minis y o Heal h, Belmopan, Cayo, Belize (P J Allen MPH); Saudi Minis y o Heal h, Riyadh, Saudi A abia (M A AlMaz oa MD, P o Z A Memish MD); Cha i é Uni e si ä smedizin Be lin, Be lin, Ge many (U Alsha i DMD, S Nol e PhD, C Papach is ou PhD); Spanish Obse a o y on D ugs, Go e nmen Delega ion o he Na ional Plan on D ugs (E Al a ez PhD), and Di ision o Pha macoepidemiology and Pha maco igilance, Spanish Medicines and Heal hca e P oduc s Agency (F Ca alá-López PhD), Minis y o Heal h, Social Se ices and Equali y, Mad id, Spain (E Al a ez PhD); Uni e sidad de Ca agena, Ca agena de Indias, Colombia (P o N Al is-Guzmán PhD); Albany S a e Uni e si y, Albany, GA, USA (P o A A Amankwaa PhD); Depa men o Epidemiology, Uni e si y o G oningen, G oningen, Ne he lands (A T Ama e MPH); College o Medicine and Heal h Sciences, Bahi Da Uni e si y, Bahi Da , E hiopia (A T Ama e); Ku dis an En i onmen al Heal h Resea ch Cen e, Ku dis an Uni e si y o Medical Sciences, Sanandaj, Ku dis an, I an (H Amini MSPH); Minis y o Public Heal h, Bei u , Lebanon (W Amma PhD, H L Ha b MPH); College o Public Heal h, Uni e si y o he Philippines Manila, Manila, Philippines (C A T An onio MD, E J A Fa aon MD); UN Popula ion Fund, Kabul, A ghanis an (P Anwa i MSc); Uppsala Uni e si y, Uppsala, Sweden (J Ä nlö PhD, P o A La sson PhD); Ins i u e o Mic obiology and Immunology, School o Medicine, Uni e si y o Belg ade, Belg ade, Se bia (P o V S A sic A senije ic PhD); Median, Windso , ON, Canada (A A aman PhD); Minis y o Heal h, Amman, Jo dan (M M Asad PhD); Field Epidemiology and Labo a o y T aining P og am, Islamabad, Pakis an (R J Asgha MD); Mashhad Uni e si y o Medical Sciences, Mashhad, I an (R Assadi MD); Minis y O Heal h, Wellness, Human Se ices and Gende Rela ions, Sans Souci, Cas ies, Sain Lucia (L S A kins MPH); Public Heal h Agency o Canada, To on o, ON, Canada (A Badawi PhD); S i Ramachand a Uni e si y, Chennai, India (K Balak ishnan PhD); School o Heal h Sciences, Uni e si y o Can e bu y, Ch is chu ch, New Zealand (A Basu PhD); School o Medicine (L Ga ikin D PH); S an o d Uni e si y, S an o d, CA, USA (S Basu PhD); Ox o d Uni e si y, Ho Chi Minh Ci y, Vie nam (J Bea dsley MBChB); College o Public Heal h and T opical Medicine, Jazan, Saudi A abia (N Bedi MD); Madawalabu Uni e si y, Bale Goba, O omia, E hiopia (T Bekele MPH); Yale Uni e si y, New Ha en, CT, USA (P o M L Bell PhD); King’s College London, London, UK (E Be nabe PhD); Addis Ababa Uni e si y, Deb e Zei , E hiopia (T J Beyene MSC, K De ibe MPH); Aga Khan Uni e si y Medical Cen e (P o Z Bhu a PhD); Aga Khan Uni e si y (M I Nisa MSc); Ka achi, Pakis an; Uni e si y o Missou i-Kansas Ci y, Kansas Ci y, MO, USA (A Bin Abdulhak MD); Gene alDi ec o a e o Heal h Resea ch (B Bo a Basa a PhD, U Dilmen MD, G K Yen u PhD); Minis y o Heal h, Anka a, Tu key (S B Uzun MD); Wo ld Bank, Washing on, DC, USA (D Bose PhD); Uni e si y o A izona, Tucson, AZ, USA (P o N B ei bo de PhD); Uni e sidad Au onoma Me opoli ana, Mexico Kassebaum e al. Page 18 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Ci y, Mexico (R Cá denas ScD); Colombian Na ional Heal h Obse a o y, Ins i u o Nacional de Salud, Bogo a, Colombia (C A Cas añeda-O juela MSc); Uni e sidad Diego Po ales, San iago, Chile (R E Cas o PhD); College o Public Heal h (H-H Lin ScD), Na ional Taiwan Uni e si y, Taipei, Taiwan (P o J- C Chang PhD); Na ional Ins i u es o Heal h, Depa men o Heal h and Human Se ices, Be hesda, MD, USA (X Che PhD); Cyp us Uni e si y o Technology, Limassol, Cyp us (C A Ch is ophi PhD); Ceda s-Sinai Medical Cen e, Los Angeles, CA, USA (P o S S Chugh MD); Uni e si y o Sale no, Ba onissi, I aly (P o M Ci illo MD); Mayo Clinic, Roches e , MN, USA (L T Coope MD); Medical Resea ch Council Li ecou se Epidemiology Uni , Uni e si y o Sou hamp on, Sou hamp on, UK (P o C Coope FMedSci); Na ional School o Public Heal h (ENSP/Fioc uz), Rio de Janei o, B azil (I da Cos a Lei e PhD); Public Heal h Founda ion o India, New Delhi, India (P o L Dandona, R Dandona PhD, G A Kuma PhD, R B Kuma MD); Public Heal h England, London, UK (P o A Da is PhD); School o Medicine (A Dayama MD), Emo y Uni e si y, A lan a, GA, USA (P o Y Liu PhD, S B Ome PhD); The Ki by Ins i u e (A J Vallely PhD), Uni e si y o New Sou h Wales, Sydney, NSW, Aus alia (P o L Degenha d PhD); G i i h Uni e si y, B isbane, QLD, Aus alia (P o D De Leo DSc); Uni e si y o Auckland, Auckland, New Zealand (B del Pozo-C uz PhD); A ica Medical and Resea ch Founda ion in E hiopia, Addis Ababa, E hiopia (M Dessalegn MPH); Hospi al o Sick Child en, Uni e si y o To on o, To on o, ON, Canada (G A deVebe MD); Uni e si y o Pe adeniya, Pe adeniya, S i Lanka (S D Dha ma a ne MD); Ha a d School o Public Heal h (E L Ding ScD), Ha a d Uni e si y, Bos on, MA, USA (P o J A Salomon PhD); Ha e Ins i u e o Ca dio ascula Resea ch in A ica, Facul y o Heal h Sciences (P o K Sliwa PhD), Uni e si y o Cape Town, Cape Town, Sou h A ica (P o R E Do ing on MPhil); Sydney School o Public Heal h (T R D iscoll PhD), Uni e si y o Sydney, NSW, Aus alia (J Leigh PhD); The Ins i u e o Social and Economic S udies o Popula ion a he Russian Academy o Sciences, Moscow, Russia (P o S P E mako DSc); Non-Communicable Diseases Resea ch Cen e (F Fa zad a MD); Endoc inology and Me abolism Resea ch Cen e (P o A Es eghama i MD, N Ha ezi-Nejad MD, S Sheikhbahaei MD), Diges i e Diseases Resea ch Ins i u e (S G Sepanlou MD), MS Resea ch Cen e (M A Sah aian MD), Sina T auma and Su ge y Resea ch Cen e (P o V Rahimi-Mo agha MD), Teh an Uni e si y o Medical Sciences, Teh an, I an; Depa amen o de Saúde Pública, ARS No e IP, Po o, Po ugal (M M Felicio MD, C M Teixei a MD); Depa men o Medical Epidemiology and Bios a is ics (E Weide pass PhD), Ka olinska Ins i u e , S ockholm, Sweden (S-M Fe esh ehnejad MD, R Ha moelle MD); No he n Region Heal h Adminis a ion (V M P Machado MSc), Public Heal h Depa men , Unidade Local de Saúde de Ma osinhos, Po o, Po ugal (G M Fe ei a de Lima BSC); Fede al Uni e si y o Minas Ge ais, Belo Ho izon e, B azil (E B F anca PhD); Na ional Cen e o Disease Con ol and Public Heal h o Geo gia, Tbilisi, Geo gia (K Gambashidze MS, K Kazanjan MS, M Ke eselidze MD, M Shakh-Naza o a MS, L S u ua PhD); Clinique Coopé a i e de Pa akou, Pa akou, Bo gou, Benin (F G Gankpé MD); Public Heal h Uni o Kassebaum e al. Page 19 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s P ima y Heal h Ca e G oup o Almada-Seixal, Almada, Se úbal, Po ugal (A C Ga cia MPH); Di ision o Human Nu i ion, Wageningen Uni e si y, Wageningen, Ne he lands (J M Geleijnse PhD); Monash Uni e si y, Melbou ne, VIC, Aus alia (K B Gibney MBBS, B K Lloyd PhD); Uni e si y Hospi al o Dijon, Dijon, F ance (P o M Gi oud MD); Helle School o Social Policy and Managemen (E L Glase MA), B andeis Uni e si y, Wal ham, MA, USA (B T Id iso MD, E A Undu aga PhD); Minis y o Labou , Heal h and Social A ai s, Tbilisi, Geo gia (K Goginash ili MPH); Uni e si y o Massachuse s Medical School, Wo ces e , MA, USA (P o P Gona PhD); Na ional Ins i u e o Public Heal h, Cue na aca, Mexico (D González-Cas ell MSc, I B He edia Pi PhD, F Mejia-Rod iguez MSc, J C Mon añez He nandez MSc, T G Sánchez Pimien a MSc, E E Se an-Mo i MSc, S Villalpando PhD, P o R Lozano); Depa men o Diabe es Resea ch, Na ional Cen e o Global Heal h and Medicine, Tokyo, Japan (A Go o PhD); School o Popula ion Heal h (D G Hoy PhD), Uni e si y o Queensland, B isbane, QLD, Aus alia (H N Gouda PhD, L Knibbs PhD); Sain James School o Medicine, K alendijk, Bonai e, Ne he lands (P o H C Gugnani PhD); Kanawha Cha les on Heal h Depa men , Cha les on, WV, USA (Rahul Gup a MD); Fo is Esco s Hospi al, Jaipu , India (Rajee Gup a PhD); A abian Gul Uni e si y, Manama, Bah ain (P o R R Hamadeh DPhil); Wayne Coun y Depa men o Heal h and Human Se ices, De oi , MI, USA (M Hammami MD); School o Medicine and Pha macology, Uni e si y o Wes e n Aus alia, Pe h, WA, Aus alia (P o G J Hankey MD); Pa nassia Psychia ic Ins i u e, The Hague, Ne he lands (H W Hoek MD); Albe Eins ein College o Medicine, B onx, NY, USA (P o H D Hosgood PhD); Public Heal h Di ision, Sec e a ia o he Paci ic Communi y, Noumea, New Caledonia (D G Hoy); Bi zei Uni e si y, Bi zei , Ramallah, Pales ine (A Husseini PhD); Na ional Ins i u e o Heal h De elopmen , Tallinn, Es onia (K Innos PhD, M Leinsalu PhD); School o Public Heal h (P o N Kawakami MD), G adua e School o Medicine (M Inoue PhD), Uni e si y o Tokyo, Tokyo, Japan (P o K Shibuya MD); Geo ge Mason Uni e si y, Fai ax, VA, USA (K H Jacobsen PhD); Ochsne Medical Cen e, New O leans, LA, USA (E Jahangi MD); G adua e School o Public Heal h, Yonsei Uni e si y, Seoul, Sou h Ko ea (P o S H Jee PhD); Pos g adua e Ins i u e o Medical Educa ion and Resea ch, Chandiga h, India (P o V Jha DM); Tianjin Cen es o Diseases Con ol and P e en ion, Tianjin, China (G Jiang MD); Depa men o Oph halmology, Medical Facul y Mannheim, Uni e si y o Heidelbe g, Heidelbe g, Ge many (P o J B Jonas MD); Na ional Ins i u e o Public Heal h, Copenhagen, Denma k (P o K Juel PhD); Vande bil Uni e si y, Nash ille, TN, USA (E K Kabagambe PhD, U Sampson MD); Fudan Uni e si y, Shanghai, China (H Kan MD); Uni e si y o Balamand, Bei u , Lebanon (N E Ka am MD); Helmhol z Cen e o In ec ion Resea ch, B aunschweig, Ge many (A Ka ch MD); Mala ia and O he Pa asi ic Diseases Di ision (C K Ka ema MSc), Minis y o Heal h, Kigali, Rwanda (F Sayinzoga MD); Oklahoma S a e Uni e si y, Tulsa, OK, USA (A Kaul MD); Uni e si y o Cali o nia San F ancisco, San F ancisco, CA, USA (D S Kazi MD); Uni e si y o São Paulo, São Paulo, B azil (P o A H Kemp PhD, P o P A Lo u o D PH, P o G Kassebaum e al. Page 20 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s V Polanczyk PhD, P o I S San os PhD); Sou h A ican Medical Resea ch Council, Cape Town, Sou h A ica (A P Kengne PhD); Jo dan Uni e si y o Science and Technology, Al-Ram ha, Jo dan (P o Y S Khade ScD); Sup eme Council o Heal h, Doha, Qa a (S E A H Khali a MSc); Heal h Se ices Academy, Islamabad, Pakis an (E A Khan MPH); Ins i u e o Heal h Policy and Managemen , Seoul Na ional Uni e si y College o Medicine, Seoul, Sou h Ko ea (P o Y-H Khang PhD); Depa men o P e en i e Ca diology, Depa men o P e en i e Medicine and Epidemiologic In o ma ics, Na ional Ce eb al and Ca dio ascula Cen e, Sui a, Japan (Y Kokubo PhD); Cen e o Communi y Empowe men , Heal h Policy and Humani ies, Na ional Ins i u e o Heal h Resea ch and De elopmen , Jaka a, Indonesia (S Kosen MD); Uni e si y o Mon eal, Mon eal, QC, Canada (P o B Kua e De o PhD); Raj ajeshwa i Medical College and Hospi al, Bangalo e, India (P o C Kulka ni PhD); A kansas S a e Uni e si y, Jonesbo o, AR, USA (V S Kulka ni PhD); In e na ional Ins i u e o Popula ion Sciences, Mumbai, India (K Kuma MPS); Indian Ins i u e o Public Heal h, Public Heal h Founda ion o India, Gu gaon, India (R B Kuma ); Bos on Medical Cen e, Bos on, MA, USA (G Kwan MD); Fou h View Consul ing, Tallinn, Es onia (T Lai PhD); Aus alian Resea ch Cen e o Popula ion O al Heal h (ARCPOH), School o Den is y, Uni e si y o Adelaide, Adelaide, SA, Aus alia (P o R Lalloo PhD); Ins i u e o Heal h Policy and De elopmen S udies, Na ional Ins i u es o Heal h, Manila, Philippines (P o H Lam PhD); In e na ional Agency o he P e en ion o Blindness and Vision 2020, Wes on, FL, USA (V C Lansingh PhD); Ko ea Uni e si y, Seoul, Sou h Ko ea (P o J-T Lee PhD, S-J Yoon PhD); Uni e si y a Albany, Rensselae , NY, USA (R Leung PhD); Na ional Cen e o Bi h De ec s Moni o ing o China, Chengdu, China (X Li MD); Na ional Cen e o Ch onic and Non-Communicable Disease Con ol and P e en ion (Yichong Li MPH, S Liu PhD, J Ma PhD, P o L Wang MD, P o M Zhou PhD), Na ional Ins i u e o Occupa ional Heal h and Poison Con ol (P o F Tan MD), Chinese Cen e o Disease Con ol and P e en ion, Beijing, China (X Liang PhD); Genen ech, Sou h San F ancisco, CA, USA (Yongmei Li PhD); Na ional O ice o Ma e nal and Child Heal h Su eillance, Wes China Second Uni e si y Hospi al, Sichuan Uni e si y, Chengdu, China (P o J Liang MD, P o Y Wang MS, P o J Zhu MD); Wayne S a e Uni e si y, Miami, FL, USA (S E Lipshul z MD); Na ional Ins i u e o En i onmen al Heal h Sciences, Resea ch T iangle Pa k, NC, USA (S J London MD); Minis y o Heal h Singapo e, Singapo e, Singapo e (S Ma PhD); Xpha mconsul , Kumasi, Ghana (N K Mainoo MMRCB); Depa men o Public Heal h, Facul y o Heal h Sciences and Social Wo k, T na a Uni e si y, T na a, Slo akia (M Majdan PhD); Uni e si y o Zambia, Lusaka, Zambia (C C Mapoma PhD); Queen Ma y Uni e si y o London, London, UK (P o W Ma cenes PhD); Uni e si y o he Eas Ramon Magsaysay Memo ial Medical Cen e, Quezon Ci y, Philippines (M B Ma zan MSPH); Uni e si y o Yo k, Yo k, UK (A J Mason-Jones PhD); Janakpu i Supe Special y Hospi al, New Delhi, India (P o M M Mehndi a a MD); UN Popula ion Fund, Lima, Pe u (W Mendoza MD); Paci ic Ins i u e o Resea ch and E alua ion, Cal e on, MD, USA (T R Kassebaum e al. Page 21 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Mille PhD); Uni e si y o O awa, O awa, ON, Canada (E J Mills PhD); Uni e si y o Papua New Guinea, Po Mo esby, Papua New Guinea (P o G L Mola MD); Ins i u e o Ma e nal and Child Heal h Is i u o di Rico e o e Cu a a Ca a e e Scien i ico Bu lo Ga o olo, T ies e, I aly (L Monas a DSc, L Ron ani PhD); Bu eau o In e na ional Heal h Coope a ion, Manila Ci y, Philippines (J de la C uz Monis MSc); Uni e si y o No h Texas, Den on, TX, USA (P o A R Moo e PhD); I an Uni e si y o Medical Sciences, Depa men o Communi y Medicine, Teh an, I an (M Mo adi-Lakeh); Na ional Cen e o Child Heal h and De elopmen , Se agaya, Tokyo, Japan (R Mo i PhD); Philipps-Uni e si y Ma bu g, Ma bu g, Ge many (P o U O Muelle PhD, R Wes e man PhD); Tokyo Medical and Den al Uni e si y, Tokyo, Japan (M Mukaigawa a MD); In e na ional Cen e o Dia hoeal Diseases Resea ch, Dhaka, Bangladesh (A Naheed PhD); Uni e si y o KwaZulu-Na al, Du ban, Sou h A ica (P o K S Naidoo PhD); Minis y o Heal h Fiji, Su a, Fiji (D Nand MPH); Su aj Eye Ins i u e, Nagpu , India (P o V Nangia MD); School o Public Heal h, Ci y Uni e si y o New Yo k, New Yo k, NY, USA (D Nash PhD); Facul y o Medicine, Fez, Mo occo (P o C Nejja i PhD); Na ional Ins i u e o Diabe es and Diges i e and Kidney Diseases, Phoenix, AZ, USA (R G Nelson PhD); No wegian Cen e o Addic ion Resea ch (SERAF), Uni e si y o Oslo, Oslo, No way (S P Neupane MBBS); Kenya Medical Resea ch Ins i u e Wellcome T us P og amme, Kili i, Kenya (P o C R New on MD); Cen e o Resea ch in En i onmen al Epidemiology (CREAL), Ba celona, Spain (M J Nieuwenhuijsen PhD); Uni e si y o Be gen, Be gen, No way (P o O F No heim PhD); Kyung Hee Un e si y, Seoul, Sou h Ko ea (I-H Oh PhD); Teikyo Uni e si y School o Medicine, Tokyo, Japan (P o T Ohkubo MD); Cen e o Heal hy S a Ini ia i e, Lagos, Nige ia (B O Olusanya PhD); Li a Dis ic Local Go e nmen , Li a Municipal Council, Li a, Uganda (J N Opio MPH); Toxicology Uni , Facul y o Pha macy, Uni e si y o Po Ha cou , Po Ha cou , Nige ia (P o O E O isakwe PhD); Ch is ian Medical College Ludhiana, Ludhiana, India (J D Pandian MD); Sungkyunkwan Uni e si y School o Medicine, Suwon, Sou h Ko ea (P o J-H Pa k MPH); Uni e sidad de Ca agena, Ca agena, Colombia (A J Pa e nina Caicedo MSc); Uni e si y o Calga y, Calga y, AB, Canada (P o S B Pa en PhD); All India Ins i u e o Medical Sciences (AIIMS), New Delhi, India (P o V K Paul MD); WHO, Waigani, Papua New Guinea (B I Pa lin MD); London School o Hygiene & T opical Medicine, London, UK (P o N Pea ce PhD); 3B’s Resea ch G oup in Bioma e ials, Biodeg adables and Biomime ics, Uni e si y o Minho, Headqua e s o he Eu opean Ins i u e o Excellence on Tissue Enginee ing and Regene a i e Medicine, and ICVS/3B’s PT Go e nmen Associa e Labo a o y, B aga Po ugal (P o D M Pe ei a PhD); Flinde s Uni e si y, Adelaide, SA, Aus alia (P o K Pesudo s PhD); Cen e o Applied Bios a is ics, Sahlg enska Academy, Uni e si y o Go henbu g, Sweden (P o M Pe zold PhD); McMas e Uni e si y, Hamil on, ON, Canada (D Poena u MD); E asmus Medical Cen e , Depa men o Public Heal h, Ro e dam, Ne he lands (S Polinde PhD); Uni e si y o Li e pool, Li e pool, UK (D Pope PhD); Uni e si y o B i ish Columbia, Vancou e , BC, Canada (F Pou malek Kassebaum e al. Page 22 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s PhD); College o Pha macy (D Qa o PhD), Uni e si y o Illinois, Chicago, IL, USA (K M Tabb PhD); Con ech In e na ional, Laho e, Pakis an (A Ra ay MS); Hamad Medical Co po a ion, Doha, Qa a (S u Rahman FRCPCH); Uni e si y o Missou i, Columbia, MO, USA (M Raju PhD); Depa men o Public Heal h, Uni e si y o he Punjab, Laho e, Pakis an (S M Rana PhD); Walden Uni e si y, Minneapolis, MN, USA (P o A Re aa PhD); Bhaba A omic Resea ch Cen e Hospi al, Mumbai, India (N Roy MD); Ma shall Uni e si y, Hun ing on, WV, USA (M Sawhney PhD); Fede al Uni e si y o San a Ca a ina, Flo ianópolis, B azil (I J C Schneide PhD); Uni e si y o Alabama a Bi mingham, Bi mingham, AL, USA (D C Schwebel PhD, J A Singh MD); S ellenbosch Uni e si y, Cape Town, Sou h A ica (P o S Seeda PhD); Heal h Canada, O awa, ON, Canada (H H Shin PhD, S Weichen hal PhD); He io -Wa Uni e si y, Edinbu gh, UK (I Shiue PhD); Reykja ik Uni e si y, Reykja ik, Iceland (I D Sig usdo i PhD); Uni e si y o Pennsyl ania, Philadelphia, PA, USA (P o D H Silbe be g MD); Ins i u o Nacional de Epidemiología D Juan H Ja a, Ma del Pla a, Buenos Ai es, A gen ina (A P Sil a MgSc); No wegian Ins i u e o Public Heal h, Oslo, No way (P o V Ski bekk PhD); Fede al Resea ch Ins i u e o Heal h O ganisa ion and In o ma ics o Minis y o Heal h o he Russian Fede a ion, Moscow, Russia (S S Soshniko PhD); Depa men o Clinical Neu ological Sciences, Wes e n Uni e si y, London, ON, Canada (L A Sposa o MD); Uni e si y Tunku Abdul Rahman, Kajang, Malaysia (C T S ee ama eddy MD); Hellenic Cen e o Disease Con ol and P e en ion (KEELPNO) G eece, A hens, G eece (K S oumpoulis PhD); Depa men o C iminology, Law and Socie y (and Sociology), Uni e si y o Cali o nia I ine, I ine, CA, USA (B L Sykes PhD); Minis y o Public Heal h, Yaounde, Came oon (R T Talongwa MD); Memo ial Uni e si y, S John’s, NL, Canada (E Y Tenko ang PhD); Depa men o Anes hesiology, Uni e si y o Vi ginia, Cha lo es ille, VA, USA (A S Te kawi MD); Depa men o Anes hesiology, King Fahad Medical Ci y, Riyadh, Saudi A abia (A S Te kawi); The Ea h Ins i u e, Columbia Uni e si y, New Yo k, NY, USA (A L Tho ne-Lyman ScD); Cincinna i Child en’s Hospi al Medical Cen e, Cincinna i, OH, USA (P o J A Towbin MD); Johns Hopkins Bloombe g School o Public Heal h, Bal imo e, MD, USA (B X T an PhD); Depa men o Medicine, Uni e si y o C e e, He aklion, G eece (P o M Tsilimba is PhD); Depa men o Ve e ans A ai s, Washing on, DC, USA (U S Uchendu MD); Depa men o In e nal Medicine, Fede al Teaching Hospi al Abakaliki, Abakaliki, Nige ia (K N Ukwaja MD); Na ional Ins i u e o Public Heal h and he En i onmen , Bil ho en, Ne he lands (C H an Gool PhD); UKK Ins i u e o Heal h P omo ion Resea ch, Tampe e, Finland (P o T J Vasanka i PhD); Neu oscience Cen e, Ra les Hospi al, Singapo e (N Venke asub amanian MD); Uni e si y o Bologna, Bologna, I aly (P o F S Violan e MD); Highe School o Economics, Moscow, Russia (P o V V Vlasso MD); Uni o med Se ices Uni e si y o Heal h Sciences, Be hesda, MD, USA (S Walle MD); Shandong Uni e si y A ilia ed Jinan Cen al Hospi al, Jinan, China (X R Wang PhD); Mu doch Child en’s Resea ch Ins i u e, Royal Child en’s Hospi al, Melbou ne, VIC, Aus alia (R G Wein aub); Uni e si y o Miami, Miami, FL, USA (J D Wilkinson Kassebaum e al. Page 23 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s MD); Ins i u e o Public Heal h, Uni e si y o Gonda , Gonda , E hiopia (S M Woldeyohannes MPH); A eneo School o Medicine and Public Heal h, Ci y o Pasig, Manila, Philippines (J Q Wong MD); Jimma Uni e si y, Jimma, E hiopia (M A Wo do a MPH); Nanjing Uni e si y School o Medicine, Jinling Hospi al, Nanjing, China (P o G Xu PhD); Uni e si y o No h Ca olina a Chapel Hill, Chapel Hill, NC, USA (Y C Yang PhD); Di ision o Ca dio ascula Medicine, Jichi Medical Uni e si y School o Medicine, Shimo suke, Japan (Y Yano MD); Uni e si y o Hong Kong, Hong Kong Special Adminis a i e Region, China (P o P Yip PhD); Na ional Cen e o Neu ology and Psychia y, Kodai a, Japan (N Yonemo o MPH); Jackson S a e Uni e si y, Jackson, MS, USA (P o M Z Younis PhD); Depa men o Epidemiology and Bios a is ics, Global Heal h Ins i u e, School o Public Heal h, Wuhan Uni e si y, Wuhan, China (P o C Yu PhD); TCM Medical Tk, Nusajaya, Joho Bah u, Malaysia (K Yun Jin PhD); Mansou a Facul y o Medicine, Mansou a, Egyp (P o M E S Zaki MD); Chongqing Medical Uni e si y, Chongqing, China (P o Y Zhao MD); Zhongshan Oph halmic Cen e, Sun Ya -sen Uni e si y, Guangzhou, China (Y Zheng PhD); and Cance Ins i u e and Hospi al, Chinese Academy o Medical Sciences, Beijing, China (P o X N Zou MD) A ilia ions (N J Kassebaum MD, A Be ozzi-Villa BA, M S Coggeshall BA, K A Shackel o d BA, C S eine MPH, K R Heu on BS, D Gonzalez-Medina BA, R Ba be BS, C Huynh BA, D Dicke BS, T Templin BA, T M Wolock BA, P o L Dandona PhD, M H Fo ouzan a MD, S S Lim PhD, P o A H Mokdad PhD, M Mo adi-Lakeh MD, M Ng MD, A Schumache BS, P o T Vos PhD, H Wang PhD, M Nagha i PhD, P o C J L Mu ay PhD, P o R Lozano MD), Depa men o Neu ology (D L Ti schwell MD), Pedia ic Anes hesiology and Pain Medicine, Sea le Child en’s Hospi al, School o Medicine (N J Kassebaum), Uni e si y o Washing on, Sea le, WA, USA (R Al onso-C is ancho PhD, P N Jensen MPH, D A Quis be g PhD, M S Va ilala MD); Hace epe Uni e si y Ins i u e o Popula ion S udies, Anka a, Tu key (A Abbasoglu Ozgo en MA, A Ca lin PhD); Facul y o Medicine, Cai o Uni e si y, Cai o, Egyp (P o F Abd-Allah MD); School o Public Heal h, College o Heal h Sciences, Mekelle Uni e si y, Mekelle, Tig ay, E hiopia (S F Abe a MSc); Uni e si y College London, London, UK (P o I Abubaka PhD); Minis y o Heal h, Gabo one, Bo swana (T Achoki PhD); Public Heal h P omo ion Alliance, Osogbp, Nige ia (A Adelekan PhD); Cen e o In e na ional Child Heal h (S M Colquhoun PhD), Uni e si y o Melbou ne, Melbou ne, VIC, Aus alia (Z Ademi PhD, J D Blo e PhD, R G Wein aub MB, P o A D Lopez PhD); Associa ion I oi ienne Pou Le Bien E e Familial, Abidjan, Cô e d’I oi e (A K Adou MD); Uni e si y o Ex emadu a, Cáce es, Spain (P o J C Adsua PhD); Ins i u ion o Public Heal h Sciences, S ockholm, Sweden (E E Aga dh PhD); Make e e Uni e si y, Kampala, Uganda (D Akena PhD, L Nyaka ahuka MPH); Minis y o Heal h, Musca , Oman (D Alas oo MSc, M J Al Kahbou i PhD); Deb e Ma kos Uni e si y, Deb e Ma kos, Amha a, E hiopia (Z A Kassebaum e al. Page 24 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Alemu MPH); Na ional Gua d Heal h A ai s, Riyadh, Saudi A abia (S Alhabib PhD); Uni e si y o Ox o d, Ox o d, UK (R Ali MSc, P o S I Hay DPhil, K Rahimi DM); School o Public Heal h, Uni e si y o Lo aine, Nancy, F ance (P o F Alla PhD); Minis y o Heal h, Belmopan, Cayo, Belize (P J Allen MPH); Saudi Minis y o Heal h, Riyadh, Saudi A abia (M A AlMaz oa MD, P o Z A Memish MD); Cha i é Uni e si ä smedizin Be lin, Be lin, Ge many (U Alsha i DMD, S Nol e PhD, C Papach is ou PhD); Spanish Obse a o y on D ugs, Go e nmen Delega ion o he Na ional Plan on D ugs (E Al a ez PhD), and Di ision o Pha macoepidemiology and Pha maco igilance, Spanish Medicines and Heal hca e P oduc s Agency (F Ca alá-López PhD), Minis y o Heal h, Social Se ices and Equali y, Mad id, Spain (E Al a ez PhD); Uni e sidad de Ca agena, Ca agena de Indias, Colombia (P o N Al is-Guzmán PhD); Albany S a e Uni e si y, Albany, GA, USA (P o A A Amankwaa PhD); Depa men o Epidemiology, Uni e si y o G oningen, G oningen, Ne he lands (A T Ama e MPH); College o Medicine and Heal h Sciences, Bahi Da Uni e si y, Bahi Da , E hiopia (A T Ama e); Ku dis an En i onmen al Heal h Resea ch Cen e, Ku dis an Uni e si y o Medical Sciences, Sanandaj, Ku dis an, I an (H Amini MSPH); Minis y o Public Heal h, Bei u , Lebanon (W Amma PhD, H L Ha b MPH); College o Public Heal h, Uni e si y o he Philippines Manila, Manila, Philippines (C A T An onio MD, E J A Fa aon MD); UN Popula ion Fund, Kabul, A ghanis an (P Anwa i MSc); Uppsala Uni e si y, Uppsala, Sweden (J Ä nlö PhD, P o A La sson PhD); Ins i u e o Mic obiology and Immunology, School o Medicine, Uni e si y o Belg ade, Belg ade, Se bia (P o V S A sic A senije ic PhD); Median, Windso , ON, Canada (A A aman PhD); Minis y o Heal h, Amman, Jo dan (M M Asad PhD); Field Epidemiology and Labo a o y T aining P og am, Islamabad, Pakis an (R J Asgha MD); Mashhad Uni e si y o Medical Sciences, Mashhad, I an (R Assadi MD); Minis y O Heal h, Wellness, Human Se ices and Gende Rela ions, Sans Souci, Cas ies, Sain Lucia (L S A kins MPH); Public Heal h Agency o Canada, To on o, ON, Canada (A Badawi PhD); S i Ramachand a Uni e si y, Chennai, India (K Balak ishnan PhD); School o Heal h Sciences, Uni e si y o Can e bu y, Ch is chu ch, New Zealand (A Basu PhD); School o Medicine (L Ga ikin D PH); S an o d Uni e si y, S an o d, CA, USA (S Basu PhD); Ox o d Uni e si y, Ho Chi Minh Ci y, Vie nam (J Bea dsley MBChB); College o Public Heal h and T opical Medicine, Jazan, Saudi A abia (N Bedi MD); Madawalabu Uni e si y, Bale Goba, O omia, E hiopia (T Bekele MPH); Yale Uni e si y, New Ha en, CT, USA (P o M L Bell PhD); King’s College London, London, UK (E Be nabe PhD); Addis Ababa Uni e si y, Deb e Zei , E hiopia (T J Beyene MSC, K De ibe MPH); Aga Khan Uni e si y Medical Cen e (P o Z Bhu a PhD); Aga Khan Uni e si y (M I Nisa MSc); Ka achi, Pakis an; Uni e si y o Missou i-Kansas Ci y, Kansas Ci y, MO, USA (A Bin Abdulhak MD); Gene alDi ec o a e o Heal h Resea ch (B Bo a Basa a PhD, U Dilmen MD, G K Yen u PhD); Minis y o Heal h, Anka a, Tu key (S B Uzun MD); Wo ld Bank, Washing on, DC, USA (D Bose PhD); Uni e si y o A izona, Tucson, AZ, USA (P o N B ei bo de PhD); Uni e sidad Au onoma Me opoli ana, Mexico Kassebaum e al. Page 25 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s 6. WHO, UNICEF, UN Popula ion Fund, Wo ld Bank. [accessed Jan 31, 2014] T ends in ma e nal mo ali y: 1990 o 2010. 2012. h p://www.un pa.o g/webda /si e/global/sha ed/documen s/ publica ions/2012/T ends_in_ma e nal_mo ali y_A4-1.pd 7. Bhu a ZA, Chop a M, Axelson H, e al. Coun down o 2015 decade epo (2000–10): aking s ock o ma e nal, newbo n, and child su i al. Lance . 2010; 375:2032–44. [PubMed: 20569843] 8. Houn on S, De Be nis L, Hussein J, e al. Towa ds elimina ion o ma e nal dea hs: ma e nal dea hs su eillance and esponse. Rep od Heal h. 2013; 10:1. [PubMed: 23279882] 9. Leone T. Measu ing di e en ial ma e nal mo ali y using census da a in de eloping coun ies. Popul Space Place. 2013 published online July 8. DOI:10.1002/psp.1802. 10. Helle inge S, Du hé G, Kan é AM, e al. Misclassi ica ion o p egnancy- ela ed dea hs in adul mo ali y su eys: case s udy in Senegal. T op Med In Heal h. 2013; 18:27–34. [PubMed: 23130912] 11. C oss S, Bell JS, G aham WJ. Wha you coun is wha you a ge : he implica ions o ma e nal dea h classi ica ion o acking p og ess owa ds educing ma e nal mo ali y in de eloping coun ies. Bull Wo ld Heal h O gan. 2010; 88:147–53. [PubMed: 20428372] 12. Lawson GW, Kei se MJNC. Re lec ions on he ma e nal mo ali y Millennium Goal. Bi h. 2013; 40:96–102. [PubMed: 24635463] 13. Mangham LJ, Hanson K. Scaling up in in e na ional heal h: wha a e he key issues? Heal h Policy Plan. 2010; 25:85–96. [PubMed: 20071454] 14. Nagha i M, Makela S, Fo eman K, O’B ien J, Pou malek F, Lozano R. Algo i hms o enhancing public heal h u ili y o na ional causes-o -dea h da a. Popul Heal h Me . 2010; 8:9. [PubMed: 20459720] 15. Nagha i M, Wang H, Vos T, e al. Global, egional, and na ional le els o age-speci ic mo ali y and 239 causes o dea h du ing 1990–2013: a sys ema ic analysis o he Global Bu den o Disease S udy 2013. Lance . submi ed. 16. Lozano R, Nagha i M, Fo eman K, e al. Global and egional mo ali y om 235 causes o dea h o 20 age g oups in 1990 and 2010: a sys ema ic analysis o he Global Bu den o Disease S udy 2010. Lance . 2012; 380:2095–128. [PubMed: 23245604] 17. WHO. In e na ional s a is ical classi ica ion o diseases and ela ed heal h p oblems: en h e ision. 2004; 2 h p://www.who.in /classi ica ions/icd/ICD-10_2nd_ed_ olume2.pd . 18. Con iden ial Enqui y in o Ma e nal and Child Heal h. Why mo he s die: 2000–2002. Royal College o Obs e icians and Gynaecologis s P ess; London: 2004. 19. Ronsmans C, G aham WJ, on behal o The Lance Ma e nal Su i al Se ies s ee ing g oup. Ma e nal mo ali y: who, when, whe e, and why. Lance . 2006; 368:1189–200. [PubMed: 17011946] 20. UN De elopmen G oup. [accessed Feb 1, 2014] Indica o s o moni o ing he Millennium De elopmen Goals: de ini ions, a ionale, concep s, and sou ces. 2003. h p://www.undp.o g/ con en /dam/aplaws/publica ion/en/publica ions/po e y- educ ion/po e y-websi e/indica o s- o - moni o ing- he-mdgs/Indica o s_ o _Moni o ing_ he_MDGs.pd 21. Gakidou E, King G. Dea h by su ey: es ima ing adul mo ali y wi hou selec ion bias om sibling su i al da a. Demog aphy. 2006; 43:569–85. [PubMed: 17051828] 22. Cal e C, Ronsmans C. The con ibu ion o HIV o p egnancy- ela ed mo ali y: a sys ema ic e iew and me a-analysis. AIDS. 2013; 27:1631–39. [PubMed: 23435296] 23. Le Coeu S, Khla M, Halembokaka G, e al. HIV and he magni ude o p egnancy- ela ed mo ali y in Poin e Noi e, Congo. AIDS. 2005; 19:69–75. [PubMed: 15627035] 24. Lionel J, Aleyamma TK, Va ghese L, e al. HIV and obs e ic complica ions and e al ou comes in Vello e, India. T op Doc . 2008; 38:144–46. [PubMed: 18628535] 25. Louis J, Landon MB, Ge sno iez RJ, e al. Pe iope a i e mo bidi y and mo ali y among human immunode iciency i us in ec ed women unde going cesa ean deli e y. Obs e Gynecol. 2007; 110:385–90. [PubMed: 17666615] 26. Kou is AP, Bansil P, McPhee e s M, Meikle SF, Posne SF, Jamieson DJ. Hospi aliza ions o p egnan HIV-in ec ed women in he USA p io o and du ing he e a o HAART, 1994–2003. AIDS. 2006; 20:1823–31. [PubMed: 16954723] Kassebaum e al. Page 32 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s 27. Khan M, Pillay T, Moodley JM, Connolly CA, o he Du ban Pe ina al TB HIV-1 S udy G oup. Ma e nal mo ali y associa ed wi h ube culosis-HIV-1 co-in ec ion in Du ban, Sou h A ica. AIDS. 2001; 15:1857–63. [PubMed: 11579249] 28. De G oo MR, Co po aal LJ, C onjé HS, Joube G. HIV in ec ion in c i ically ill obs e ical pa ien s. In J Gynaecol Obs e . 2003; 81:9–16. [PubMed: 12676387] 29. Coley JL, Msamanga GI, Fawzi MC, e al. The associa ion be ween ma e nal HIV-1 in ec ion and p egnancy ou comes in Da es Salaam, Tanzania. BJOG. 2001; 108:1125–33. [PubMed: 11762650] 30. Z andasa a P, Ha g o e JW, N ozini R, e al. Mo ali y and mo bidi y among pos pa um HIV- posi i e and HIV-nega i e women in Zimbabwe: isk ac o s, causes, and impac o single-dose pos pa um i amin A supplemen a ion. J Acqui Immune De ic Synd . 2006; 43:107–16. [PubMed: 16885772] 31. Sewankambo NK, G ay RH, Ahmad S, e al. Mo ali y associa ed wi h HIV in ec ion in u al Rakai Dis ic , Uganda. AIDS. 2000; 14:2391–400. [PubMed: 11089628] 32. McDe mo JM, Slu ske L, S eke ee RW, Wi ima JJ, B eman JG, Heymann DL. P ospec i e assessmen o mo ali y among a coho o p egnan women in u al Malawi. Am J T op Med Hyg. 1996; 55:66–70. [PubMed: 8702040] 33. Black V, B ooke S, Che sich MF. E ec o human immunode iciency i us ea men on ma e nal mo ali y a a e ia y cen e in Sou h A ica: a 5-yea audi . Obs e Gynecol. 2009; 114:292–99. [PubMed: 19622990] 34. Zaba B, Cal e C, Ma s on M, e al. E ec o HIV in ec ion on p egnancy- ela ed mo ali y in sub-Saha an A ica: seconda y analyses o pooled communi y-based da a om he ne wo k o Analysing Longi udinal Popula ion-based HIV/AIDS da a on A ica (ALPHA). Lance . 2013; 381:1763–71. [PubMed: 23683643] 35. Mmi o F, Ndugwa C, Guay L, e al. E ec o human immunode iciency i us-1 in ec ion on he ou come o p egnancy in Ugandan women. Pedia AIDS HIV In ec . 1993; 4:67–73. 36. Temme man M, Chomba EN, Ndinya-Achola J, Plumme FA, Coppens M, Pio P. Ma e nal human immunode iciency i us-1 in ec ion and p egnancy ou come. Obs e Gynecol. 1994; 83:495–501. [PubMed: 7907777] 37. Na hoo K, Rusakaniko S, Zijenah LS, e al. Su i al pa e n among in an s bo n o human immunode iciency i us ype-1 in ec ed mo he s and unin ec ed mo he s in Ha a e, Zimbabwe. Cen A J Med. 2004; 50:1–6. [PubMed: 15490717] 38. Kuma RM, Uduman SA, Khu anna AK. Impac o ma e nal HIV-1 in ec ion on pe ina al ou come. In J Gynaecol Obs e . 1995; 49:137–43. [PubMed: 7649317] 39. Nuwagaba-Bi ibonwoha H, Mayon-Whi e RT, Okong P, Ca pen e LM, Jenkinson C. The impac o HIV on ma e nal quali y o li e in Uganda. AIDS Ca e. 2006; 18:614–20. [PubMed: 16831790] 40. Maiques-Mon esinos V, Ce e a-Sanchez J, Bell e -P adas J, Abad-Ca ascosa A, Se a-Se a V. Pos -cesa ean sec ion mo bidi y in HIV-posi i e women. Ac a Obs e Gynecol Scand. 1999; 78:789–92. [PubMed: 10535342] 41. Ryde RW, Nsuami M, Nsa W, e al. Mo ali y in HIV-1-se oposi i e women, hei spouses and hei newly bo n child en du ing 36 mon hs o ollow-up in Kinshasa, Zaï e. AIDS. 1994; 8:667– 72. [PubMed: 8060546] 42. Lepage P, Dabis F, Hi imana DG, e al. Pe ina al ansmission o HIV-1: lack o impac o ma e nal HIV in ec ion on cha ac e is ics o li ebi hs and on neona al mo ali y in Kigali, Rwanda. AIDS. 1991; 5:295–300. [PubMed: 2059369] 43. Chilongozi D, Wang L, B own L, e al. Mo bidi y and mo ali y among a coho o human immunode iciency i us ype 1-in ec ed and unin ec ed p egnan women and hei in an s om Malawi, Zambia, and Tanzania. Pedia In ec Dis J. 2008; 27:808–14. [PubMed: 18679152] 44. Ma hews LT, Kaida A, Kan e s S, e al. HIV-in ec ed women on an i e o i al ea men ha e inc eased mo ali y du ing p egnan and pos pa um pe iods. AIDS. 2013; 27(suppl 1):S105–112. [PubMed: 24088676] 45. Wes eich D, Maskew M, E ans D, Fi nhabe C, Majuba P, Sanne I. Inciden p egnancy and ime o dea h o AIDS among HIV-posi i e women ecei ing an i e o i al he apy. PloS One. 2013; 8:e58117. [PubMed: 23520489] Kassebaum e al. Page 33 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s 46. Fo eman KJ, Lozano R, Lopez AD, Mu ay CJ. Modeling causes o dea h: an in eg a ed app oach using CODEm. Popul Heal h Me . 2012; 10:1. [PubMed: 22226226] 47. Romano M, Caccia o e A, Gio dano R, La Rosa B. Pos pa um pe iod: h ee dis inc bu con inuous phases. J P ena Med. 2010; 4:22–25. [PubMed: 22439056] 48. Jamison DT, Summe s LH, Alleyne G, e al. Global heal h 2035: a wo ld con e ging wi hin a gene a ion. Lance . 2013; 382:1898–955. [PubMed: 24309475] 49. Ins i u e o Heal h Me ics and E alua ion. Financing global heal h 2013: ansi ion in an age o aus e i y. Ins i u e o Heal h Me ics and E alua ion; Sea le, WA: 2014. 50. Konje JC, Ladipo OA. Nu i ion and obs uc ed labo . Am J Clin Nu . 2000; 72(suppl 1):291–97S. 51. Bhu a ZA, Das JK, Riz i A, e al. E idence-based in e en ions o imp o emen o ma e nal and child nu i ion: wha can be done and a wha cos ? Lance . 2013; 382:452–77. [PubMed: 23746776] 52. Bhu a ZA, Ahmed T, Black RE, e al. Wha wo ks? In e en ions o ma e nal and child unde nu i ion and su i al. Lance . 2008; 371:417–40. [PubMed: 18206226] 53. Acos a C, Bha acha ya S, Tu nell D, Ku inczuk J, Knigh M. Ma e nal sepsis: a Sco ish popula ion-based case-con ol s udy. BJOG. 2012; 119:474–83. [PubMed: 22251396] 54. Say L, Pa inson RC, Gülmezoglu AM. WHO sys ema ic e iew o ma e nal mo bidi y and mo ali y: he p e alence o se e e acu e ma e nal mo bidi y (nea miss). Rep od Heal h. 2004; 1:3. [PubMed: 15357863] 55. Mo gan J, Robe s S. Ma e nal sepsis. Obs e Gynecol Clin No h Am. 2013; 40:69–87. [PubMed: 23466138] 56. Asnani MR, McCaw-Binns AM, Reid ME. Excess isk o ma e nal dea h om sickle cell disease in Jamaica: 1998–2007. PloS One. 2011; 6:e26281. [PubMed: 22039456] 57. Wilkinson H, on behal o he T us ees and Medical Ad ise s. Sa ing mo he s’ li es. Re iewing ma e nal dea hs o make mo he hood sa e : 2006–2008. BJOG. 2011; 118:1402–03. [PubMed: 21906238] 58. Rahimy MC, Gangbo A, Adjou R, Deguenon C, Goussanou S, Alihonou E. E ec o ac i e p ena al managemen on p egnancy ou come in sickle cell disease in an A ican se ing. Blood. 2000; 96:1685–89. [PubMed: 10961864] 59. Ne is IF, Rei sma A, Dominic A, e al. P egnancy ou comes in women wi h ch onic kidney disease: a sys ema ic e iew. Clin J Am Soc Neph ol. 2011; 6:2587–98. [PubMed: 21940842] 60. Gilbe WM, Young AL, Danielsen B. P egnancy ou comes in women wi h ch onic hype ension: a popula ion-based s udy. J Rep od Med. 2007; 52:1046–51. [PubMed: 18161404] 61. B a SS, Khan SS, Sandhu GK, e al. Incidence, mo ali y, and acial di e ences in pe ipa um ca diomyopa hy. Am J Ca diol. 2007; 100:302–04. [PubMed: 17631087] 62. Goland S, Modi K, Bi a F, e al. Clinical p o ile and p edic o s o complica ions in pe ipa um ca diomyopa hy. J Ca d Fail. 2009; 15:645–50. [PubMed: 19786252] 63. Sliwa K, Fe J, Elkayam U. Pe ipa um ca diomyopa hy. Lance . 2006; 368:687–93. [PubMed: 16920474] 64. Maman AFO-B, Tom a K, Ahouangbé i S, Chobli M. Dea hs associa ed wi h anaes hesia in Togo, Wes A ica. T op Doc . 2005; 35:220–22. [PubMed: 16354475] 65. The An i e o i al The apy in Lowe Income Coun ies (ART-LINC) Collabo a ion and ART Coho Collabo a ion (ART-CC) g oups. Mo ali y o HIV-1-in ec ed pa ien s in he i s yea o an i e o i al he apy: compa ison be ween low-income and high-income coun ies. Lance . 2006; 367:817–24. [PubMed: 16530575] 66. Mu ay CJL, O blad KF, Guino a C, e al. Global, egional, and na ional incidence and dea h o HIV, ube culosis, and mala ia du ing 1990-2013: a sys ema ic analysis o he Global Bu den o Disease S udy 2013. Lance . submi ed. 67. Wo ld Heal h O ganiza ion Maximizing Posi i e Syne gies Collabo a i e G oup. An assessmen o in e ac ions be ween global heal h ini ia i es and coun y heal h sys ems. Lance . 2009; 373:2137– 69. [PubMed: 19541040] 68. Colbou n T, Lewycka S, Nambia B, Anwa I, Phoya A, Mhango C. Ma e nal mo ali y in Malawi, 1977–2012. BMJ Open. 2013; 3:e004150. Kassebaum e al. Page 34 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s 69. Wang H, Dwye -Lindg en L, Lo g en KT, e al. Age-speci ic and sex-speci ic mo ali y in 187 coun ies, 1970–2010: a sys ema ic analysis o he Global Bu den o Disease S udy 2010. Lance . 2012; 380:2071–94. [PubMed: 23245603] 70. Yusu HR, Akh e HH, Rahman MH, Chowdhu y ME, Rocha RW. Inju y- ela ed dea hs among women aged 10–50 yea s in Bangladesh, 1996–97. Lance . 2000; 355:1220–24. [PubMed: 10770304] 71. Gissle M, Be g C, Bou ie -Colle M-H, Buekens P. Inju y dea hs, suicides and homicides associa ed wi h p egnancy, Finland 1987-2000. Eu J Public Heal h. 2005; 15:459–63. [PubMed: 16051655] 72. Shahidullah M. The sis e hood me hod o es ima ing ma e nal mo ali y: he Ma lab expe ience. S ud Fam Plann. 1995; 26:101–06. [PubMed: 7618193] 73. Hill K, Thomas K, AbouZah C, e al. Es ima es o ma e nal mo ali y wo ldwide be ween 1990 and 2005: an assessmen o a ailable da a. Lance . 2007; 370:1311–19. [PubMed: 17933645] 74. Con oy AL, McDonald CR, Kain KC. Mala ia in p egnancy: diagnosing in ec ion and iden i ying e al isk. Expe Re An i In ec The . 2012; 10:1331–42. [PubMed: 23241190] Kassebaum e al. Page 35 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Panel: Resea ch in con ex Ou analysis con inues a body o analy ical wo k in o le els and ends in ma e nal mo ali y ha began wi h Hogan and colleagues’ epo 4 and was ollowed by ha by Lozano and colleagues5 and he Global Bu den o Disease S udy 2010 (GBD 2010).16 Wi h each subsequen s udy, he e ha e been impo an ad ances in he da a a ailable o analysis and he me hods o analysis. Lozano and colleagues5 mo ed om one p e e ed eg ession model, as used by Hogan and colleagues and he UN measu emen e o s,6,20 o an ensemble o mul iple models de eloped h ough igo ous ou -o -sample p edic i e alidi y es ing. The ma e nal mo ali y analysis included in GBD 2010 ex ended he analysis in wo impo an ways: ma e nal mo ali y was assessed wi h all o he causes o dea h subjec o he cons ain ha sum o indi idual causes o dea h equalled he demog aphic assessmen o all-cause mo ali y in each age g oup o ep oduc i e-age women, and i included es ima es o he majo causes o ma e nal mo ali y. In ou s udy, in addi ion o 2421 si e-yea s o new da a, se e al impo an me hodological inno a ions imp o e he es ima ion o ma e nal mo ali y. Fi s , we ha e analysed sibling his o y da a o he ac ion o ep oduc i e-age dea hs ha a e ela ed o p egnancy by calenda yea o each 5-yea age g oup o mo he s, pooling da a om se e al su eys when e en s o he same calenda yea we e eco ded. Second, we ha e subs an ially e ised he app oach o unde s and he e ec o HIV on ma e nal mo ali y. We did a sys ema ic e iew and used ela i e isks om coho s udies o accu a ely assign a ai ly small ac ion o HIV- ela ed dea hs du ing p egnancy o he pue pe ium o be ma e nal dea hs. Thi d, we ha e quan i ied o he di ec ma e nal causes, indi ec ma e nal causes, and la e ma e nal dea h o he i s ime. Fou h, we ha e analysed p e ious epo s and o he sou ces abou he iming o ma e nal dea hs o p o ide guidance on when mos dea hs occu . Ou da a and imp o ed me hods ha e led o a di e en unde s anding o he e olu ion o global ma e nal dea hs wi h impo an implica ions o a ge se ing in he pos -MDG e a. Kassebaum e al. Page 36 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Figu e 1. De ini ions o ma e nal dea h ICD-10=In e na ional Classi ica ion o Diseases, e sion 10. *Du ing labou and up o 24 h a e deli e y. †Be ween 24 h and 6 weeks a e deli e y. ‡Be ween 6 weeks and 1 yea a e deli e y. Kassebaum e al. Page 37 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Figu e 2. Fo es plo o he ela i e isk o dea h du ing p egnancy o women wi h HIV in ec ion compa ed wi h women wi hou HIV in ec ion Weigh s a e om andom e ec s analysis. Size o he iangles is p opo ional o he weigh ing o each s udy in he me a-analysis. UI=unce ain y in e al. Kassebaum e al. Page 38 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Figu e 3. Global ma e nal dea hs (A) and annualised a e o change in ma e nal mo ali y a io (B), 1990–2013 Shaded a eas show 95% unce ain y in e als. Kassebaum e al. Page 39 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Figu e 4. Global ma e nal mo ali y a io in 1990 and 2013, by age Shaded a eas show 95% unce ain y in e als. Kassebaum e al. Page 40 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Figu e 5. Change in MMR be ween 1990 and 2013, by egion MMR=ma e nal mo ali y a io. Kassebaum e al. Page 41 Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 48 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Mongolia 180·2 (137·4 o 233·0) 96·3 (74·6 o 122·7) 51·3 (34·2 o 72·3) 108 (82 o 139) 50 (39 o 63) 33 (22 o 46) −4·8% (−7·5 o −2·1) −6·4% (−10·7 o −2·1) −5·5% (−7·5 o −3·6) Tajikis an 74·6 (65·3 o 86·4) 49·4 (42·2 o 57·8) 30·4 (22·2 o 39·3) 154 (135 o 178) 98 (84 o 115) 82 (60 o 106) −3·2% (−4·9 o −1·6) −4·9% (−8·2 o −1·9) −3·9% (−5·4 o −2·7) Tu kmenis an 72·9 (63·2 o 83·1) 61·2 (41·1 o 83·7) 38·2 (22·9 o 55·5) 91 (79 o 103) 64 (43 o 88) 42 (25 o 61) −1·4% (−4·6 o 1·3) −4·8% (−9·7 o −0·1) −2·9% (−5·0 o −1·1) Uzbekis an 50·7 (45·4 o 56·8) 42·4 (36·6 o 48·9) 30·5 (21·0 o 42·6) 353 (315 o 395) 249 (215 o 287) 187 (129 o 262) −1·4% (−2·8 o −0·1) −3·4% (−6·8 o 0·4) −2·3% (−3·9 o −0·7) Eas Asia 139·5 (113·1 o 167·1) 63·9 (58·1 o 69·7) 18·2 (15·0 o 21·3) 31 690 (25 695 o 37 974) 11 084 (10 075 o 12 080) 3534 (2925 o 4135) −6·0% (−7·6 o −4·3) −12·6% (−14·5 o −107) −8·9% (−10·1 o −7·6) China 141·7 (114·4 o 170·8) 64·1 (58·2 o 70·1) 17·2 (14·0 o 20·3) 31 042 (25 074 o 37 428) 10 652 (9667 o 11 643) 3233 (2633 o 3815) −6·1% (−7·8 o −4·3) −13·2% (−15·2 o −11·1) −9·2% (−10·4 o −7·8) No h Ko ea 136·3 (70·2 o 226·7) 100·5 (67·8 o 144·1) 77·4 (48·3 o 111·9) 546 (281 o 908) 386 (260 o 554) 275 (172 o 398) −2·2% (−6·5 o 2·5) −2·6% (−7·4 o 2·5) −2·4% (−5·6 o 1·1) Taiwan (P o ince o China) 24·9 (17·3 o 33·8) 13·5 (10·1 o 17·8) 7·9 (6·1 o 10·2) 102 (71 o 138) 46 (34 o 60) 26 (20 o 33) −4·7% (−7·7 o −1·8) −5·3% (−9·0 o −1·7) −5·0% (−6·6 o −3·2) Sou h Asia 480·4 (407·4 o 558·3) 399·7 (345·8 o 467·6) 310·6 (252·4 o 383·4) 174 416 (147 914 o 202 689) 142 624 (123 413 o 166 876) 107 827 (87 629 o 133 087) −1·4% (−3·0 o 0·3) −2·6% (−5·1 o 0·0) −1·9% (−3·0 o −0·8) A ghanis an 501·0 (324·4 o 739·0) 716·3 (441·3 o 1123·4) 885·0 (508·7 o 1445·1) 3261 (2112 o 4811) 7726 (4760 o 12 117) 8794 (5055 o 14 360) 2·7% (−0·6 o 5·8) 2·1% (−1·8 o 5·4) 2·4% (0·1 o 4·7) Bangladesh 551·9 (436·4 o 659·5) 333·1 (250·9 o 427·6) 242·7 (171·2 o 326·9) 20 669 (16 345 o 24 701) 11 327 (8532 o 14 541) 7737 (5459 o 10 422) −3·9% (−6·4 o −1·3) −3·2% (−7·0 o 0·8) −3·6% (−5·1 o −1·9) Bhu an 551·7 (275·0 o 846·5) 411·2 (204·9 o 651·7) 277·4 (136·7 o 469·2) 106 (53 o 162) 59 (30 o 94) 40 (20 o 68) −2·3% (−6·4 o 1·5) −4·0% (−8·1 o 0·9) −3·0% (−5·8 o 0·2) India 480·8 (384·9 o 583·6) 382·0 (315·3 o 472·8) 281·8 (207·0 o 371·2) 128 695 (103 026 o 156 193) 100 014 (82 553 o 123 801) 71 792 (52 723 o 94 564) −1·8% (−4·0 o 0·6) −3·1% (−6·6 o 0·3) −2·3% (−3·9 o −0·8) Nepal 417·4 (295·9 o 540·8) 365·0 (262·6 o 464·3) 272·3 (190·9 o 363·5) 3012 (2136 o 3903) 2623 (1886 o 3336) 1588 (1113 o 2119) −1·0% (−3·6 o 1·5) −3·0% (−6·0 o −0·1) −1·9% (−3·7 o 0·1) Pakis an 423·9 (317·2 o 521·6) 486·5 (360·7 o 595·6) 400·6 (233·0 o 560·8) 18 673 (13 973 o 22 976) 20 875 (15 477 o 17 876 (10 397 o 1·1% (−1·6 o 3·7) −2·1% (−7·7 o 2·4) −0·3% (−2·9 o 1·8) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 49 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 25 557) 25 026) Sou heas Asia 295·0 (247·5 o 353·4) 217·4 (180·8 o 266·3) 154·9 (124·2 o 192·9) 35 339 (29 644 o 42 340) 25 637 (21 327 o 31 404) 18 028 (14 456 o 22 444) −2·3% (−3·6 o −1·1) −3·4% (−5·4 o −1·6) −2·8% (−4·0 o −1·8) Cambodia 355·9 (290·5 o 415·7) 399·0 (277·9 o 486·8) 220·9 (155·6 o 286·5) 1290 (1053 o 1507) 1355 (944 o 1654) 862 (607 o 1118) 0·8% (−1·8 o 2·8) −5·9% (−9·3 o −2·9) −2·1% (−3·6 o −0·6) Indonesia 368·3 (311·6 o 432·9) 262·0 (224·3 o 308·2) 199·3 (149·4 o 257·4) 16 519 (13 975 o 19 416) 12 734 (10 902 o 14 982) 9352 7010 o 12 079) −2·6% (−4·2 o −1·0) −2·8% (−6·1 o 0·0) −2·7% (−4·3 o −1·4) Laos 514·4 (276·7 o 767·0) 490·7 (251·3 o 779·6) 303·8 (154·7 o 521·5) 942 (506 o 1404) 814 (417 o 1293) 543 (277 o 932) −0·4% (−4·1 o 2·7) −4·8% (−8·3 o −1·1) −2·3% (−4·7 o 0·3) Malaysia 101·6 (84·3 o 120·3) 78·4 (70·7 o 87·5) 55·7 (43·1 o 70·6) 522 (433 o 617) 364 (328 o 406) 291 (226 o 369) −2·0% (−3·5 o −0·4) −3·5% (−6·0 o −0·8) −2·6% (−3·9 o −1·3) Maldi es 292·3 (240·8 o 355·1) 95·4 (78·7 o 111·6) 51·8 (38·6 o 67·0) 23 (19 o 28) 6 (5 o 7) 4 (3 o 5) −8·6% (−10·3 o −6·7) −6·2% (−9·5 o −3·0) −7·5% (−9·1 o −6·0) Myanma 897·3 (513·3 o 1460·4) 645·6 (332·2 o 1145·2) 390·9 (196·3 o 731·7) 9465 (5414 o 15 405) 6108 (3144 o 10 835) 3531 (1773 o 6609) −2·6% (−6·1 o 0·6) −5·1% (−8·8 o −1·0) −3·7% (−6·0 o −0·9) Philippines 116·3 (103·4 o 130·2) 81·5 (72·0 o 91·5) 80·9 (54·9 o 115·0) 2374 (2112 o 2658) 1876 (1657 o 2105) 1959 (1328 o 2784) −2·7% (−3·9 o −1·5) −0·2% (−4·3 o 3·5) −1·6% (−3·3 o −0·1) S i Lanka 73·6 (61·8 o 89·0) 47·9 (38·9 o 56·7) 30·9 (20·7 o 43·4) 257 (216 o 311) 178 (144 o 211) 116 (77 o 162) −3·3% (−5·3 o −1·7) −4·5% (−8·6 o −0·6) −3·8% (−5·9 o −2·1) Thailand 42·6 (36·1 o 50·3) 89·6 (75·9 o 104·4) 69·5 (47·3 o 98·7) 456 (386 o 538) 766 (648 o 892) 481 (328 o 684) 5·7% (3·8 o 7·5) −2·7% (−6·6 o 1·4) 2·1% (0·3 o 3·9) Timo -Les e 632·8 (490·8 o 781·3) 430·2 (361·6 o 498·6) 223·4 (175·5 o 275·9) 215 (167 o 266) 156 (131 o 181) 89 (70 o 110) −2·9% (−4·9 o −0·9) −6·6% (−9·0 o −4·2) −4·5% (−6·0 o −3·1) Vie nam 174·5 (124·5 o 239·1) 88·5 (59·4 o 122·0) 56·6 (34·1 o 89·5) 3275 (2337 o 4487) 1281 (860 o 1766) 800 (482 o 1265) −5·2% (−8·3 o −2·2) −4·6% (−9·1 o 0·0) −5·0% (−7·5 o −2·3) Aus alasia 8·1 (7·1 o 9·2) 5·9 (5·2 o 6·7) 5·5 (4·5 o 6·6) 26 (22 o 29) 19 (17 o 22) 21 (17 o 25) −2·4% (−3·7 o −1·0) −0·7% (−2·7 o 1·3) −1·7% (−2·6 o −0·6) Aus alia 7·0 (6·0 o 8·2) 5·1 (4·4 o 6·0) 4·8 (3·7 o 5·9) 18 (16 o 21) 14 (12 o 16) 15 (12 o 18) −2·5% (−4·1 o −0·8) −0·7% (−3·2 o 2·0) −1·7% (−3·0 o −0·5) New Zealand 12·6 (10·3 o 15·2) 9·4 (7·9 o 11·3) 9·3 (7·2 o 12·1) 7 (6 o 9) 6 (5 o 7) 6 (4 o 7) −2·2% (−4·2 o −0·3) −0·1% (−3·0 o 2·7) −1·3% (−2·8 o 0·1) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 50 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Ca ibbean 208·3 (165·9 o 248·8) 213·1 (161·4 o 272·2) 150·0 (110·1 o 206·7) 1664 (1325 o 1987) 1602 (1214 o 2047) 1075 (788 o 1480) 0·1% (−1·5 o 1·7) −3·5% (−6·1 o −1·0) −1·5% (−2·6 o −0·1) An igua and Ba buda 54·4 (40·1 o 69·4) 50·8 (40·1 o 64·2) 42·0 (27·9 o 62·3) 1 (1 o 1) 1 (1 o 1) 1 (0 o 1) −0·5% (−3·2 o 2·1) −2·0% (−6·4 o 2·7) −1·2% (−3·1 o 1·1) Ba bados 69·4 (54·8 o 87·4) 62·3 (50·4 o 75·0) 49·9 (34·3 o 70·7) 3 (2 o 4) 2 (2 o 3) 2 (1 o 3) −0·8% (−3·0 o 1·4) −2·3% (−6·2 o 1·7) −1·5% (−3·2 o 0·4) Belize 32·1 (26·2 o 39·5) 42·5 (34·9 o 51·6) 55·5 (37·6 o 78·9) 2 (2 o 3) 3 (2 o 4) 4 (3 o 6) 2·2% (0·1 o 4·2) 2·5% (−1·4 o 6·3) 2·3% (0·3 o 4·1) Cuba 71·1 (59·6 o 87·0) 60·6 (52·4 o 70·2) 39·8 (31·5 o 49·5) 123 (103 o 150) 82 (71 o 95) 44 (35 o 54) −1·2% (−3·0 o 0·4) −4·3% (−6·9 o −1·6) −2·5% (−3·8 o −1·2) Dominica 50·2 (39·2 o 65·9) 41·4 (32·4 o 52·2) 36·1 (23·2 o 52·7) 1 (1 o 1) 1 (0 o 1) 0 (0 o 1) −1·5% (−4·2 o 1·0) −1·5% (−5·9 o 2·6) −1·5% (−3·6 o 0·6) Dominican Republic 73·8 (62·8 o 85·8) 60·5 (52·2 o 69·8) 40·8 (28·9 o 55·8) 164 (139 o 191) 138 (119 o 159) 90 (64 o 124) −1·5% (−2·9 o 0·0) −4·1% (−7·6 o −0·8) −2·6% (−4·2 o −1·1) G enada 47·7 (37·6 o 62·4) 62·5 (50·6 o 76·6) 56·7 (41·0 o 76·9) 1 (1 o 2) 1 (1 o 1) 1 (1 o 2) 2·1% (−0·2 o 4·5) −1·1% (−4·7 o 2·4) 0·7% (−1·0 o 2·4) Guyana 118·8 (98·5 o 142·0) 138·9 (111·4 o 169·2) 118·1 (75·8 o 179·4) 21 (17 o 25) 25 (20 o 30) 20 (13 o 30) 1·2% (−1·0 o 3·3) −1·8% (−6·1 o 2·4) −0·1% (−2·1 o 2·0) Hai i 492·4 (363·4 o 619·7) 495·7 (351·1 o 662·0) 333·0 (219·1 o 480·1) 1290 (952 o 1624) 1289 (913 o 1722) 868 (571 o 1251) 0·0% (−2·0 o 2·1) −4·0% (−7·2 o −1·0) −1·7% (−3·2 o −0·1) Jamaica 44·0 (32·4 o 58·1) 59·4 (48·6 o 71·2) 44·7 (29·7 o 66·0) 27 (20 o 36) 33 (27 o 40) 23 (15 o 34) 2·3% (−0·2 o 5·0) −3·0% (−7·0 o 1·2) 0·0% (−2·0 o 2·1) Sain Lucia 52·0 (40·8 o 68·7) 44·4 (35·5 o 54·3) 41·0 (28·0 o 58·8) 2 (2 o 3) 1 (1 o 2) 1 (1 o 2) −1·2% (−3·9 o 1·3) −0·9% (−4·6 o 3·2) −1·1% (−3·1 o 0·7) Sain Vincen and he G enadines 45·2 (33·3 o 60·8) 65·7 (54·0 o 81·7) 60·1 (43·7 o 80·8) 1 (1 o 2) 1 (1 o 2) 1 (1 o 1) 2·9% (0·2 o 5·7) −1·0% (−4·6 o 2·3) 1·2% (−0·7 o 3·2) Su iname 76·8 (62·3 o 93·2) 88·2 (71·3 o 106·5) 65·2 (44·2 o 91·3) 7 (6 o 9) 9 (7 o 11) 6 (4 o 9) 1·1% (−1·1 o 3·2) −3·1% (−7·6 o 1·0) −0·8% (−2·6 o 1·1) The Bahamas 63·1 (48·0 o 84·0) 71·8 (57·5 o 90·2) 60·3 (38·8 o 91·2) 4 (3 o 5) 4 (3 o 5) 4 (2 o 5) 1·0% (−1·7 o 3·5) −1·9% (−6·5 o 2·4) −0·3% (−2·4 o 2·1) T inidad and Tobago 72·3 (61·5 o 84·3) 64·4 (54·1 o 75·8) 49·7 (36·4 o 65·6) 17 (14 o 20) 13 (11 o 15) 10 (7 o 13) −0·9% (−2·6 o 0·9) −2·7% (−5·8 o 0·5) −1·7% (−3·1 o −0·2) Cen al Eu ope 48·9 (45·4 o 53·0) 15·4 (14·1 o 16·5) 8·8 (7·5 o 10·1) 790 (734 o 856) 189 (173 o 203) 112 (95 o 128) −8·9% (−9·7 o −8·2) −5·6% (−7·1 o −4·1) −7·4% (−8·2 o −6·8) Albania 35·3 (29·5 o 41·6) 13·2 (10·8 o 16·1) 7·3 (4·9 o 10·2) 30 (25 o 35) 6 (5 o 8) 3 (2 o 4) −7·6% (−9·7 o −5·5) −6·1% (−10·4 o −2·2) −6·9% (−8·7 o −5·2) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 51 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Bosnia and He zego ina 38·8 (31·2 o 47·0) 20·4 (14·8 o 27·6) 11·0 (7·7 o 15·3) 23 (19 o 28) 7 (5 o 9) 4 (3 o 5) −5·0% (−7·8 o −2·3) −6·3% (−10·1 o −2·5) −5·5% (−7·2 o −3·8) Bulga ia 44·3 (38·8 o 50·7) 29·2 (24·9 o 33·7) 14·8 (12·0 o 18·2) 43 (37 o 49) 22 (18 o 25) 11 (9 o 13) −3·2% (−4·8 o −1·7) −6·8% (−9·0 o −4·5) −4·8% (−5·7 o −3·8) C oa ia 16·9 (14·1 o 20·1) 12·7 (10·5 o 14·9) 9·9 (7·9 o 12·3) 9 (7 o 11) 5 (4 o 6) 4 (3 o 5) −2·2% (−4·0 o −0·5) −2·5% (−4·9 o 0·0) −2·3% (−3·6 o −1·1) Czech Republic 18·1 (15·2 o 21·4) 7·0 (5·8 o 8·4) 5·3 (4·1 o 6·7) 22 (18 o 26) 7 (6 o 9) 6 (5 o 8) −7·3% (−9·2 o −5·4) −2·8% (−5·6 o −0·2) −5·3% (−6·6 o −4·1) Hunga y 19·0 (16·0 o 22·5) 9·2 (7·6 o 11·0) 8·5 (6·3 o 10·7) 24 (20 o 28) 9 (7 o 11) 9 (6 o 11) −5·6% (−7·5 o −3·7) −0·8% (−3·7 o 1·9) −3·5% (−4·9 o −2·3) Macedonia 25·1 (20·1 o 31·3) 17·7 (14·7 o 21·0) 10·5 (8·2 o 13·3) 9 (7 o 11) 4 (4 o 5) 2 (2 o 3) −2·7% (−4·8 o −0·6) −5·2% (−7·6 o −2·4) −3·8% (−5·3 o −2·3) Mon eneg o 15·9 (104 o 23·0) 18·6 (14·0 o 24·0) 12·3 (8·6 o 17·3) 1 (1 o 2) 1 (1 o 2) 1 (1 o 1) 1·3% (−2·2 o 4·7) −4·2% (−7·8 o −0·2) −1·1% (−3·3 o 1·1) Poland 34·0 (30·3 o 38·2) 8·6 (7·4 o 9·9) 4·8 (3·8 o 6·1) 179 (159 o 201) 33 (28 o 37) 20 (16 o 26) −10·6% (−12·0 o −9·3) −5·8% (−8·5 o −3·4) −8·5% (−9·6 o −7·4) Romania 152·1 (137·4 o 169·5) 31·6 (27·9 o 35·5) 15·9 (12·2 o 19·9) 414 (374 o 462) 73 (65 o 82) 37 (28 o 46) −12·1% (−13·3 o −10·9) −6·9% (−9·6 o −4·3) −9·8% (−11·1 o −8·7) Se bia 15·8 (11·0 o 22·9) 12·1 (10·1 o 14·2) 10·6 (8·5 o 13·0) 22 (15 o 32) 13 (11 o 16) 10 (8 o 12) −2·0% (−5·1 o 1·0) −1·3% (−3·8 o 1·2) −1·7% (−3·6 o 0·1) Slo akia 15·9 (12·7 o 19·5) 9·5 (8·0 o 11·1) 6·2 (4·8 o 7·9) 12 (10 o 15) 5 (4 o 6) 4 (3 o 5) −4·0% (−6·1 o −2·0) −4·3% (−7·1 o −1·6) −4·1% (−5·5 o −2·8) Slo enia 12·9 (10·6 o 15·7) 11·0 (8·8 o 13·3) 7·4 (5·5 o 9·8) 3 (2 o 3) 2 (2 o 3) 2 (1 o 2) −1·2% (−3·2 o 0·8) −4·1% (−7·3 o −0·8) −2·5% (−3·9 o −1·0) Eas e n Eu ope 60·1 (54·3 o 65·7) 36·3 (32·8 o 40·4) 17·6 (14·4 o 20·6) 1566 (1415 o 1714) 812 (733 o 904) 433 (354 o 507) −3·9% (−4·9 o −2·8) −7·3% (−9·4 o −5·4) −5·3% (−6·1 o −4·6) Bela us 40·5 (35·1 o 46·3) 25·0 (20·8 o 30·0) 10·6 (7·7 o 13·9) 53 (46 o 60) 25 (20 o 30) 11 (8 o 15) −3·7% (−5·4 o −1·9) −8·7% (−11·9 o −5·5) −5·9% (−7·2 o −4·5) Es onia 45·1 (37·4 o 54·1) 17·7 (14·7 o 21·5) 7·1 (4·9 o 9·5) 8 (7 o 10) 3 (2 o 3) 1 (1 o 1) −7·2% (−9·2 o −5·3) −9·2% (−12·7 o −5·8) −8·1% (−9·9 o −6·6) La ia 49·7 (42·2 o 58·1) 20·8 (17·1 o 24·5) 8·5 (6·2 o 11·1) 16 (13 o 18) 5 (4 o 6) 2 (1 o 3) −6·7% (−8·5 o −5·0) −9·0% (−12·3 o −6·3) −7·7% (−9·2 o −6·4) Li huania 29·6 (24·9 o 34·9) 13·7 (11·5 o 16·3) 6·1 (4·6 o 7·8) 15 (13 o 18) 5 (4 o 5) 2 (2 o 3) −5·9% (−7·7 o −4·0) −8·2% (−11·1 o −5·2) −6·9% (−8·3 o −5·6) Moldo a 68·9 (59·7 o 79·6) 34·7 (28·5 o 41·3) 21·8 (16·0 o 28·2) 50 (43 o 57) 16 (13 o 19) 9 (7 o 12) −5·3% (−7·2 o −3·4) −4·7% (−7·7 o −1·8) −5·0% (−6·6 o −3·7) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 52 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Russia 64·9 (57·7 o 72·6) 36·9 (32·5 o 42·0) 16·8 (13·5 o 20·2) 1099 (976 o 1229) 575 (507 o 655) 291 (234 o 351) −4·4% (−5·7 o −2·9) −7·9% (−10·5 o −5·6) −5·9% (−6·8 o −5·0) Uk aine 53·3 (46·3 o 60·8) 39·6 (34·5 o 45·4) 23·1 (17·5 o 29·2) 326 (283 o 372) 184 (161 o 211) 116 (88 o 147) −2·3% (−3·7 o −0·8) −5·4% (−8·4 o −2·7) −3·7% (−4·9 o −2·5) Wes e n Eu ope 12·7 (11·7 o 13·8) 8·1 (7·3 o 8·6) 6·3 (5·3 o 7·1) 565 (522 o 615) 365 (330 o 390) 288 (243 o 326) −3·5% (−4·2 o −2·9) −2·5% (−3·8 o −1·4) −3·1% (−3·8 o −2·5) Ando a 5·5 (3·1 o 9·0) 3·1 (1·9 o 4·9) 3·0 (1·6 o 4·8) 0 (0 o 0) 0 (0 o 0) 0 (0 o 0) −4·4% (−9·2 o 0·1) −0·6% (−6·3 o 5·6) −2·7% (−5·9 o 0·2) Aus ia 10·3 (8·5 o 12·2) 5·0 (4·0 o 6·0) 3·2 (2·3 o 4·0) 9 (8 o 11) 4 (3 o 5) 3 (2 o 3) −5·6% (−7·5 o −3·6) −4·5% (−7·4 o −1·8) −5·1% (−6·5 o −3·8) Belgium 11·3 (9·4 o 13·3) 8·4 (6·9 o 10·1) 6·7 (5·0 o 8·6) 14 (12 o 16) 10 (8 o 12) 9 (7 o 11) −2·2% (−4·0 o −0·5) −2·3% (−5·2 o 0·5) −2·3% (−3·6 o −1·0) Cyp us 13·3 (9·6 o 17·7) 8·7 (6·7 o 11·0) 6·1 (4·4 o 8·1) 2 (1 o 3) 1 (1 o 1) 1 (1 o 1) −3·2% (−6·0 o −0·4) −3·6% (−7·4 o 0·1) −3·4% (−5·2 o −1·6) Denma k 7·4 (6·2 o 9·1) 5·8 (4·7 o 7·1) 4·8 (3·4 o 6·2) 5 (4 o 6) 4 (3 o 5) 3 (2 o 4) −1·9% (−4·4 o 0·1) −2·1% (−5·0 o 0·7) −2·0% (−3·7 o −0·5) Finland 7·2 (5·9 o 8·8) 6·4 (5·3 o 7·6) 3·9 (3·0 o 5·0) 5 (4 o 6) 4 (3 o 4) 2 (2 o 3) −0·9% (−2·8 o 1·0) −5·0% (−7·6 o −2·3) −2·7% (−4·1 o −1·4) F ance 15·6 (13·5 o 17·7) 11·0 (9·3 o 12·6) 8·8 (6·9 o 11·0) 116 (100 o 132) 87 (74 o 100) 70 (55 o 88) −2·7% (−4·1 o −1·2) −2·2% (−4·5 o 0·2) −2·5% (−3·7 o −1·3) Ge many 18·0 (15·9 o 20·4) 8·3 (7·1 o 9·6) 6·5 (5·0 o 7·9) 146 (129 o 165) 62 (52 o 71) 46 (36 o 56) −5·9% (−7·4 o −4·7) −2·5% (−4·6 o −0·5) −4·4% (−5·6 o −3·4) G eece 9·5 (8·0 o 11·1) 7·9 (6·6 o 9·3) 9·1 (7·2 o 11·3) 10 (8 o 11) 9 (7 o 11) 10 (8 o 12) −1·4% (−3·2 o 0·2) 1·4% (−1·0 o 4·0) −0·2% (−1·3 o 1·0) Iceland 7·1 (5·5 o 9·0) 4·2 (3·0 o 5·6) 2·4 (1·6 o 3·6) 0 (0 o 0) 0 (0 o 0) 0 (0 o 0) −4·1% (−7·1 o −1·1) −5·4% (−9·9 o −1·0) −4·7% (−6·9 o −2·6) I eland 6·3 (5·2 o 7·6) 3·9 (3·1 o 4·7) 3·3 (2·3 o 4·4) 3 (3 o 4) 2 (2 o 3) 2 (2 o 3) −3·7% (−5·6 o −1·9) −1·7% (−5·0 o 1·7) −2·8% (−4·4 o −1·3) Is ael 10·4 (8·8 o 12·5) 7·1 (5·9 o 8·5) 4·4 (3·2 o 5·5) 10 (9 o 12) 10 (8 o 12) 7 (5 o 9) −2·9% (−4·8 o −1·1) −4·9% (−8·2 o −2·2) −3·8% (−5·4 o −2·4) I aly 9·9 (8·6 o 11·4) 5·7 (4·7 o 6·7) 4·3 (3·2 o 5·5) 54 (47 o 63) 32 (27 o 38) 24 (18 o 32) −4·3% (−5·8 o −2·7) −2·8% (−5·7 o −0·2) −3·7% (−5·0 o −2·4) Luxembou g 5·0 (4·1 o 6·1) 7·0 (5·4 o 8·6) 6·1 (4·5 o 8·0) 0 (0 o 0) 0 (0 o 0) 0 (0 o 1) 2·6% (0·3 o 4·6) −1·5% (−4·7 o 2·0) 0·8% (−0·8 o 2·4) Mal a 6·9 (5·5 o 8·4) 5·4 (4·2 o 6·9) 2·9 (2·0 o 3·9) 0 (0 o 1) 0 (0 o 0) 0 (0 o 0) −1·8% (−4·3 o 0·5) −6·5% (−10·4 o −2·8) −3·8% (−5·6 o −2·1) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 53 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Ne he lands 11·7 (9·8 o 13·9) 10·8 (8·9 o 12·7) 6·7 (5·1 o 8·3) 23 (19 o 27) 22 (18 o 25) 12 (9 o 15) −0·6% (−2·3 o 1·0) −4·8% (−7·4 o −2·1) −2·5% (−3·7 o −1·3) No way 5·9 (4·9 o 7·1) 6·3 (5·1 o 7·7) 4·5 (3·5 o 5·6) 4 (3 o 4) 4 (3 o 5) 3 (2 o 4) 0·5% (−1·4 o 2·5) −3·4% (−6·0 o −0·7) −1·2% (−2·4 o 0·1) Po ugal 20·6 (17·7 o 24·1) 13·6 (11·5 o 16·0) 9·8 (7·7 o 12·2) 23 (20 o 27) 15 (13 o 17) 9 (7 o 11) −3·2% (−4·9 o −1·5) −3·3% (−6·0 o −0·8) −3·3% (−4·4 o −2·1) Spain 12·3 (10·7 o 14·3) 7·0 (6·0 o 8·2) 6·2 (4·8 o 7·6) 47 (41 o 54) 32 (28 o 37) 31 (24 o 38) −4·3% (−5·8 o −2·8) −1·4% (−3·8 o 1·2) −3·0% (−4·2 o −1·9) Sweden 7·0 (5·7 o 8·6) 4·9 (3·9 o 5·9) 3·7 (2·7 o 4·8) 8 (7 o 10) 5 (4 o 6) 4 (3 o 6) −2·7% (−4·9 o −0·7) −2·8% (−6·1 o 0·1) −2·7% (−4·5 o −1·3) Swi ze land 6·7 (5·5 o 8·3) 5·8 (4·6 o 7·2) 3·9 (2·9 o 5·1) 5 (4 o 7) 4 (3 o 5) 3 (2 o 4) −1·1% (−3·4 o 1·1) −4·0% (−7·0 o −1·0) −2·3% (−4·1 o −0·9) UK 10·4 (9·4 o 11·1) 7·7 (7·0 o 8·3) 6·1 (5·2 o 6·9) 80 (73 o 86) 57 (52 o 62) 47 (40 o 54) −2·3% (−2·9 o −1·7) −2·4% (−3·8 o −1·0) −2·3% (−3·0 o −1·7) Andean La in Ame ica 187·9 (169·5 o 208·7) 112·5 (99·7 o 125·1) 96·0 (75·3 o 117·2) 2249 (2028 o 2497) 1366 (1211 o 1520) 1164 (912 o 1421) −4·0% (−5·2 o −2·8) −1·6% (−4·0 o 0·6) −2·9% (−4·1 o −2·0) Boli ia 382·4 (312·1 o 458·1) 229·9 (178·7 o 281·9) 179·6 (110·4 o 257·2) 977 (798 o 1171) 616 (479 o 755) 499 (307 o 715) −3·9% (−6·3 o −1·7) −2·6% (−6·9 o 1·3) −3·4% (−5·6 o −1·5) Ecuado 142·7 (128·4 o 159·9) 86·0 (72·8 o 100·3) 84·6 (57·7 o 122·0) 430 (386 o 481) 282 (239 o 329) 282 (192 o 406) −3·9% (−5·4 o −2·4) −0·3% (−4·6 o 3·7) −2·3% (−4·1 o −0·7) Pe u 131·5 (114·1 o 152·6) 75·7 (64·6 o 88·4) 63·7 (45·6 o 85·4) 842 (731 o 977) 468 (400 o 547) 383 (274 o 513) −4·3% (−5·9 o −2·6) −1·8% (−5·2 o 1·6) −3·2% (−4·8 o −1·7) Cen al La in Ame ica 78·8 (74·9 o 82·3) 67·9 (63·7 o 72·6) 59·9 (53·8 o 66·7) 3884 (3690 o 4056) 3446 (3231 o 3683) 2950 (2649 o 3283) −1·1% (−1·6 o −0·7) −1·3% (−2·2 o −0·2) −1·2% (−1·6 o −0·7) Colombia 68·2 (60·7 o 76·7) 77·1 (67·2 o 87·7) 62·9 (44·1 o 85·2) 633 (563 o 712) 725 (632 o 824) 577 (405 o 782) 0·9% (−0·3 o 2·2) −2·2% (−5·6 o 1·2) −0·4% (−1·9 o 1·0) Cos a Rica 314 (26·9 o 36·0) 36·3 (31·7 o 41·5) 24·9 (20·1 o 30·3) 25 (22 o 29) 28 (24 o 31) 19 (15 o 23) 1·2% (−0·3 o 2·7) −3·8% (−6·0 o −1·5) −1·0% (−2·0 o 0·1) El Sal ado 105·5 (90·2 o 120·4) 57·5 (49·2 o 66·5) 65·8 (44·3 o 91·6) 181 (155 o 206) 77 (66 o 89) 86 (58 o 119) −4·7% (−6·3 o −3·1) 1·2% (−2·6 o 4·9) −2·1% (−3·8 o −0·4) Gua emala 112·8 (101·0 o 126·2) 91·8 (81·2 o 104·2) 86·7 (65·8 o 110·8) 409 (367 o 458) 400 (353 o 454) 423 (321 o 541) −1·6% (−2·8 o −0·4) −0·6% (−3·5 o 2·0) −1·2% (−2·4 o 0·0) Hondu as 153·1 (90·5 o 190·4) 119·5 (48·5 o 191·2) 72·0 (35·5 o 123·0) 295 (175 o 367) 238 (97 o 381) 153 (75 o 260) −2·1% (−6·4 o 1·5) −5·1% (−10·5 o 0·2) −3·4% (−5·8 o −1·1) Mexico 73·8 (70·4 o 77·1) 57·9 (55·0 o 60·5) 54·0 (50·3 o 58·2) 1774 (1691 1429 (1357 1224 (1139 −1·9% (−2·3 o −1·5) −0·7% (−1·5 o 0·1) −1·4% (−1·7 o −1·0) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 54 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 o 1851) o 1493) o 1320) Nica agua 94·5 (81·2 o 109·4) 87·8 (76·7 o 101·0) 63·5 (49·0 o 80·0) 148 (127 o 171) 126 (110 o 145) 90 (69 o 113) −0·6% (−2·1 o 1·0) −3·3% (−6·2 o −0·7) −1·8% (−3·0 o −0·5) Panama 62·3 (53·0 o 72·7) 66·2 (57·2 o 76·3) 55·2 (40·6 o 73·2) 42 (35 o 49) 50 (44 o 58) 42 (31 o 56) 0·5% (−1·1 o 2·2) −1·9% (−5·1 o 1·3) −0·6% (−1·9 o 0·8) Venezuela 66·6 (59·6 o 73·5) 62·0 (56·3 o 68·7) 54·7 (42·8 o 68·6) 377 (337 o 415) 373 (339 o 413) 336 (263 o 421) −0·5% (−1·6 o 0·5) −1·3% (−3·8 o 1·2) −0·9% (−2·0 o 0·2) Sou he n La in Ame ica 55·5 (51·1 o 60·2) 51·2 (46·3 o 55·8) 44·2 (37·3 o 51·3) 603 (555 o 653) 513 (465 o 560) 445 (376 o 518) −0·6% (−1·6 o 0·2) −1·5% (−3·3 o 0·3) −1·0% (−1·8 o −0·2) A gen ina 60·2 (54·9 o 66·0) 63·3 (57·0 o 69·7) 54·7 (45·3 o 64·6) 434 (396 o 476) 440 (396 o 484) 387 (320 o 456) 0·4% (−0·7 o 1·4) −1·5% (−3·5 o 0·5) −0·4% (−1·3 o 0·4) Chile 47·8 (42·3 o 54·3) 22·0 (19·3 o 25·0) 18·7 (14·7 o 23·2) 146 (130 o 166) 56 (49 o 64) 47 (37 o 58) −6·0% (−7·4 o −4·6) −1·7% (−4·2 o 0·9) −4·1% (−5·2 o −3·0) U uguay 38·7 (32·8 o 45·3) 32·5 (27·4 o 38·1) 22·9 (17·3 o 29·4) 23 (19 o 27) 17 (15 o 20) 12 (9 o 15) −1·4% (−3·0 o 0·3) −3·6% (−6·5 o −0·7) −2·3% (−3·6 o −1·0) T opical La in Ame ica 75·9 (68·0 o 84·6) 68·3 (60·9 o 75·6) 60·6 (47·5 o 75·6) 2818 (2522 o 3139) 2445 (2182 o 2708) 1969 (1542 o 2457) −0·8% (−1·9 o 0·2) −1·2% (−3·9 o 1·3) −1·0% (−2·2 o 0·1) B azil 73·1 (65·0 o 82·0) 66·0 (58·4 o 73·7) 58·7 (45·8 o 73·5) 2609 (2320 o 2925) 2265 (2003 o 2530) 1813 (1414 o 2267) −0·8% (−1·9 o 0·3) −1·2% (−4·0 o 1·4) −1·0% (−2·2 o 0·2) Pa aguay 145·6 (130·2 o 162·4) 119·8 (107·3 o 134·0) 95·2 (71·6 o 126·9) 209 (187 o 233) 181 (162 o 202) 156 (117 o 208) −1·5% (−2·7 o −0·3) −2·4% (−5·3 o 1·0) −1·9% (−3·2 o −0·5) No h A ica and Middle Eas 131·0 (115·4 o 147·8) 101·8 (85·1 o 121·3) 78·1 (63·1 o 97·6) 13 106 (11 543 o 14 783) 10 370 (8672 o 12 351) 8907 (7204 o 11 135) −2·0% (−3·2 o −0·9) −2·7% (−4·3 o −1·0) −2·3% (−3·2 o −1·3) Alge ia 126·1 (87·0 o 170·4) 81·0 (59·8 o 107·0) 51·5 (37·2 o 70·1) 949 (655 o 1283) 575 (424 o 759) 470 (340 o 641) −3·4% (−6·5 o 0·1) −4·5% (−8·6 o −0·5) −3·9% (−5·8 o −2·0) Bah ain 55·4 (40·7 o 73·4) 32·7 (24·9 o 41·9) 21·4 (15·5 o 29·0) 7 (5 o 10) 5 (4 o 6) 4 (3 o 6) −4·0% (−6·9 o −1·1) −4·3% (−8·0 o 0·1) −4·2% (−6·1 o −2·2) Egyp 83·7 (69·9 o 100·1) 44·8 (39·1 o 51·9) 32·6 (24·5 o 42·3) 1385 (1157 o 1656) 765 (668 o 888) 619 (465 o 803) −4·8% (−6·5 o −3·0) −3·2% (−6·2 o −0·3) −4·1% (−5·5 o −2·8) I an 40·1 (27·0 o 57·2) 26·6 (21·9 o 31·6) 13·5 (9·4 o 18·3) 651 (439 o 929) 333 (275 o 396) 197 (137 o 266) −3·1% (−6·2 o 0·2) −6·9% (−10·9 o −3·1) −4·7% (−7·0 o −2·6) I aq 110·6 (68·7 o 157·0) 88·0 (62·0 o 126·8) 65·8 (40·4 o 110·7) 736 (457 o 1045) 816 (574 o 1175) 695 (427 o 1170) −1·7% (−5·6 o 2·5) −3·1% (−8·1 o 2·3) −2·3% (−4·8 o 0·7) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 55 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Jo dan 102·2 (79·1 o 128·7) 60·2 (46·2 o 78·8) 29·8 (20·3 o 41·4) 112 (87 o 141) 92 (71 o 120) 57 (39 o 79) −4·1% (−6·9 o −1·3) −7·1% (−11·8 o −2·2) −5·4% (−7·2 o −3·5) Kuwai 17·8 (14·4 o 21·6) 11·4 (9·6 o 13·6) 9·5 (7·5 o 12·0) 6 (5 o 7) 5 (5 o 7) 7 (5 o 8) −3·4% (−5·4 o −1·4) −1·8% (−4·4 o 0·8) −2·7% (−4·0 o −1·4) Lebanon 101·4 (74·8 o 135·1) 42·4 (30·8 o 56·8) 18·1 (11·9 o 26·0) 65 (48 o 87) 23 (16 o 30) 12 (8 o 17) −6·7% (−9·5 o −3·9) −8·6% (−12·7 o −4·9) −7·5% (−9·7 o −5·5) Libya 41·8 (25·7 o 64·6) 30·7 (22·8 o 40·5) 27·0 (18·0 o 40·5) 46 (28 o 71) 37 (27 o 49) 33 (22 o 50) −2·3% (−6·0 o 1·6) −1·4% (−6·5 o 3·7) −1·9% (−4·5 o 0·8) Mo occo 279·5 (236·0 o 338·9) 98·3 (75·2 o 120·8) 63·9 (45·1 o 85·8) 1971 (1664 o 2390) 603 (462 o 741) 472 (334 o 635) −8·1% (−10·2 o −6·0) −4·4% (−7·5 o −1·3) −6·5% (−8·1 o −5·0) Oman 47·0 (26·7 o 76·6) 20·4 (14·2 o 29·4) 12·8 (8·4 o 20·6) 30 (17 o 49) 11 (7 o 15) 9 (6 o 15) −6·3% (−10·8 o −1·7) −4·8% (−10·8 o 1·2) −5·6% (−8·5 o −2·8) Pales ine 21·1 (12·3 o 34·3) 11·3 (8·7 o 14·4) 9·0 (5·5 o 13·2) 22 (13 o 35) 13 (10 o 17) 12 (7 o 17) −4·6% (−9·0 o −0·4) −2·5% (−7·5 o 2·3) −3·7% (−6·8 o −0·7) Qa a 50·4 (36·2 o 69·8) 38·9 (29·6 o 50·1) 18·7 (12·4 o 27·2) 5 (4 o 7) 4 (3 o 6) 4 (3 o 6) −2·0% (−5·1 o 1·0) −7·4% (−12·2 o −2·8) −4·3% (−6·6 o −2·2) Saudi A abia 15·7 (9·1 o 25·2) 9·3 (7·6 o 11·1) 7·0 (5·2 o 9·2) 88 (51 o 140) 49 (41 o 59) 38 (28 o 50) −3·8% (−7·9 o 0·6) −2·8% (−6·2 o 0·5) −3·4% (−5·8 o −0·8) Sudan 407·8 (304·2 o 502·9) 356·5 (237·6 o 478·8) 275·2 (181·1 o 377·5) 3558 (2654 o 4388) 4193 (2794 o 5631) 3528 (2322 o 4840) −1·1% (−3·5 o 1·1) −2·6% (−5·4 o 0·2) −1·8% (−3·3 o −0·2) Sy ia 120·5 (86·0 o 158·8) 64·8 (49·1 o 80·9) 44·1 (31·1 o 60·3) 513 (367 o 676) 309 (235 o 386) 229 (161 o 313) −4·7% (−7·7 o −1·8) −3·9% (−7·7 o 0·1) −4·4% (−6·4 o −2·4) Tunisia 62·2 (44·4 o 82·7) 28·5 (18·4 o 42·3) 19·0 (11·6 o 28·5) 124 (88 o 164) 48 (31 o 72) 35 (21 o 53) −6·1% (−9·7 o −2·4) −4·1% (−9·1 o 0·7) −5·2% (−7·6 o −3·0) Tu key 48·5 (34·7 o 65·2) 23·1 (17·1 o 30·9) 15·0 (10·7 o 19·9) 664 (475 o 893) 304 (226 o 408) 188 (134 o 250) −5·7% (−8·9 o −2·6) −4·3% (−8·4 o −0·1) −5·1% (−6·9 o −3·2) Uni ed A ab Emi a es 55·8 (31·0 o 112·1) 21·6 (14·1 o 33·7) 12·8 (7·7 o 21·4) 23 (13 o 47) 12 (8 o 18) 17 (10 o 29) −7·1% (−11·9 o −2·4) −5·3% (−10·2 o 1·0) −6·3% (−9·5 o −3·0) Yemen 342·6 (182·1 o 519·2) 322·2 (182·7 o 524·9) 308·8 (168·6 o 555·4) 2151 (1143 o 3260) 2172 (1232 o 3538) 2279 (1244 o 4099) −0·5% (−3·5 o 2·7) −0·5% (−3·8 o 3·3) −0·5% (−2·8 o 2·2) High-income No h Ame ica 11·9 (10·7 o 13·3) 17·0 (15·1 o 18·8) 17·6 (14·3 o 21·6) 555 (499 o 621) 784 (697 o 867) 829 (672 o 1016) 2·7% (1·5 o 3·8) 0·3% (−1·8 o 2·6) 1·7% (0·7 o 2·6) Canada 7·1 (6·0 o 8·3) 9·2 (7·6 o 10·7) 8·2 (6·3 o 10·3) 28 (24 o 33) 32 (27 o 37) 33 (25 o 42) 2·0% (0·2 o 3·6) −1·2% (−3·7 o 1·3) 0·6% (−0·7 o 1·9) USA 12·4 (11·1 o 13·9) 17·6 (15·7 o 19·5) 18·5 (14·8 o 22·9) 527 (472 o 592) 752 (669 o 833) 796 (638 o 985) 2·7% (1·4 o 3·8) 0·5% (−1·8 o 2·8) 1·7% (0·8 o 2·7) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 56 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Oceania 599·9 (365·3 o 972·5) 577·8 (331·4 o 976·3) 494·1 (264·4 o 849·3) 1234 (752 o 2001) 1461 (838 o 2469) 1325 (709 o 2278) −0·3% (−3·3 o 2·7) −1·6% (−5·2 o 2·4) −0·9% (−3·2 o 1·7) Fede a ed S a es o Mic onesia 170·3 (82·9 o 310·8) 130·5 (66·6 o 235·5) 87·9 (44·7 o 154·5) 6 (3 o 10) 4 (2 o 7) 2 (1 o 4) −2·0% (−6·0 o 2·0) −3·9% (−8·5 o 0·7) −2·9% (−5·6 o 0·0) Fiji 109·6 (68·4 o 165·2) 100·8 (72·0 o 135·5) 68·2 (43·7 o 102·8) 24 (15 o 36) 19 (14 o 26) 12 (8 o 18) −0·6% (−4·4 o 3·6) −4·0% (−9·0 o 0·8) −2·1% (−4·9 o 0·7) Ki iba i 213·3 (153·9 o 296·9) 142·4 (97·1 o 216·5) 100·9 (57·4 o 169·1) 6 (4 o 8) 3 (2 o 5) 2 (1 o 4) −3·2% (−7·1 o 0·8) −3·6% (−9·0 o 1·8) −3·4% (−6·2 o −0·6) Ma shall Islands 74·7 (46·2 o 111·8) 109·4 (66·3 o 167·8) 95·6 (51·9 o 164·9) 2 (1 o 2) 2 (1 o 3) 2 (1 o 3) 2·9% (−1·6 o 7·4) −1·5% (−7·8 o 5·1) 1·0% (−2·0 o 4·0) Papua New Guinea 765·9 (456·7 o 1255·9) 702·6 (396·4 o 1197·8) 594·2 (312·7 o 1030·8) 1148 (684 o 1882) 1382 (779 o 2355) 1260 (663 o 2187) −0·7% (−3·8 o 2·4) −1·7% (−5·4 o 2·3) −1·1% (−3·6 o 1·5) Samoa 61·1 (36·2 o 99·7) 51·2 (32·5 o 76·3) 41·4 (26·9 o 62·8) 3 (2 o 5) 3 (2 o 4) 2 (1 o 3) −1·3% (−6·0 o 3·3) −2·1% (−7·0 o 3·3) −1·6% (−4·6 o 1·1) Solomon Islands 254·0 (127·4 o 454·4) 214·5 (112·5 o 379·3) 183·0 (95·9 o 338·5) 32 (16 o 56) 34 (18 o 60) 32 (17 o 59) −1·3% (−5·2 o 2·7) −1·6% (−6·0 o 3·2) −1·4% (−4·5 o 1·6) Tonga 188·1 (118·8 o 286·9) 143·3 (108·8 o 185·6) 111·2 (68·2 o 172·2) 6 (4 o 9) 4 (3 o 5) 3 (2 o 5) −2·0% (−6·0 o 1·8) −2·7% (−7·8 o 2·3) −2·3% (−5·0 o 0·4) Vanua u 176·3 (83·5 o 329·7) 174·8 (88·2 o 333·0) 139·2 (72·3 o 257·6) 10 (5 o 18) 10 (5 o 20) 9 (5 o 17) −0·1% (−4·2 o 4·1) −2·2% (−6·6 o 2·4) −1·0% (−4·0 o 2·2) Cen al sub-Saha an A ica 456·3 (366·2 o 546·7) 419·1 (341·2 o 499·8) 353·1 (279·9 o 434·1) 12 178 (9773 o 14 591) 15 191 (12 369 o 18 118) 15 355 (12 174 o 18 880) −0·7% (−2·2 o 0·8) −1·7% (−3·8 o 0·3) −1·1% (−2·3 o 0·1) Angola 510·6 (324·9 o 747·3) 451·1 (308·9 o 657·8) 310·1 (198·3 o 472·2) 2976 (1894 o 4356) 3672 (2515 o 5355) 3032 (1939 o 4618) −0·9% (−3·7 o 1·8) −3·8% (−7·1 o −0·5) −2·2% (−4·0 o 0·0) Cen al A ican Republic 788·7 (576·4 o 1020·1) 999·4 (636·2 o 1415·6) 910·5 (578·3 o 1293·2) 973 (711 o 1258) 1473 (937 o 2086) 1459 (926 o 2072) 1·8% (−0·7 o 3·9) −0·9% (−3·8 o 1·7) 0·6% (−1·0 o 2·0) Congo 397·2 (275·6 o 545·1) 482·8 (322·1 o 673·7) 287·3 (189·6 o 427·1) 379 (263 o 519) 678 (452 o 946) 494 (326 o 735) 1·5% (−1·1 o 3·9) −5·2% (−8·5 o −2·0) −1·4% (−3·4 o 0·4) DR Congo 420·1 (323·5 o 521·5) 369·5 (295·0 o 451·4) 342·3 (251·4 o 446·7) 7616 (5865 o 9455) 9069 (7241 o 11 081) 10 125 (7437 o 13 213) −1·0% (−3·1 o 1·3) −0·8% (−3·7 o 1·8) −0·9% (−2·6 o 0·7) Equa o ial Guinea 599·9 (376·2 o 897·0) 487·3 (280·4 o 736·7) 369·6 (199·8 o 620·0) 109 (68 o 163) 110 (63 o 166) 100 (54 o 168) −1·6% (−5·4 o 2·3) −2·9% (−6·9 o 1·4) −2·2% (−4·9 o 0·9) Gabon 345·7 (265·2 o 438·6) 413·0 (301·0 o 541·8) 267·3 (184·1 o 370·3) 126 (96 o 159) 189 (138 o 248) 144 (99 o 199) 1·3% (−1·3 o 4·0) −4·4% (−7·9 o −1·3) −1·2% (−2·9 o 0·6) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04. Eu ope PMC Funde s Au ho Manusc ip s Eu ope PMC Funde s Au ho Manusc ip s Kassebaum e al. Page 57 Ma e nal mo ali y a io (pe 100 000 li ebi hs) Numbe o ma e nal dea hs Annualised a e o change in ma e nal mo ali y a io (%) 1990 2003 2013 1990 2003 2013 1990–2003 2003–13 1990–2013 Eas e n sub-Saha an A ica 511·7 (461·5 o 562·3) 564·7 (490·8 o 640·0) 387·2 (331·5 o 453·0) 45 250 (40 808 o 49 719) 65 050 (56 537 o 73 735) 52 269 (44747 o 61 144) 0·7% (−0·3 o 1·9) −3·8% (−5·1 o −2·4) −1·2% (−1·8 o −0·6) Bu undi 757·1 (560·5 o 977·3) 712·3 (538·5 o 899·9) 370·8 (240·4 o 504·3) 2122 (1571 o 2739) 2240 (1693 o 2830) 1683 (1091 o 2289) −0·5% (−3·0 o 1·9) −6·6% (−10·2 o −3·7) −3·1% (−5·1 o −1·4) Como os 527·4 (319·7 o 830·5) 383·0 (219·8 o 646·7) 329·2 (171·9 o 584·5) 82 (50 o 130) 88 (50 o 148) 85 (45 o 152) −2·5% (−6·0 o 1·1) −1·7% (−6·6 o 2·6) −2·2% (−4·9 o 0·7) Djibou i 526·3 (334·8 o 788·7) 629·3 (405·3 o 962·4) 523·5 (329·8 o 821·8) 124 (79 o 186) 138 (89 o 211) 123 (77 o 193) 1·4% (−1·9 o 4−6) −1·9% (−5·2 o 1·5) 0·0% (−2·2 o 2·2) E i ea 614·2 (493·7 o 747·0) 679·9 (475·9 o 902·1) 566·0 (351·2 o 817·7) 949 (763 o 1154) 1241 (868 o 1646) 1313 (814 o 1896) 0·7% (−1·8 o 3·1) −1·9% (−5·1 o 0·9) −0·4% (−2·3 o 1·3) E hiopia 708·0 (600·4 o 815·0) 657·8 (486·3 o 839·6) 497·4 (371·5 o 648·8) 16 740 (14 197 o 19 271) 18 941 (14 001 o 24 173) 15 234 (11 378 o 19 871) −0·6% (−3·1 o 1·4) −2·8% (−5·2 o −0·2) −1·6% (−2·8 o −0·3) Kenya 315·5 (250·1 o 382·2) 559·2 (375·0 o 773·0) 277·2 (175·4 o 414·1) 3047 (2416 o 3692) 7628 (5115 o 10 543) 4361 (2759 o 6514) 4·3% (1·3 o 7·4) −7·1% (−10·8 o −3·9) −0·6% (−2·6 o 1·4) Madagasca 314·0 (246·9 o 375·5) 378·0 (255·9 o 480·7) 297·7 (174·3 o 448·6) 1723 (1355 o 2061) 2610 (1766 o 3319) 2455 (1438 o 3699) 1·4% (−1·0 o 3·4) −2·6% (−6·4 o 1·6) −0·3% (−2·3 o 1·5) Malawi 550·3 (440·5 o 669·6) 815·3 (567·4 o 1111·1) 334·7 (224·5 o 465·1) 2627 (2103 o 3197) 4542 (3161 o 6189) 2260 (1516 o 3140) 3·0% (0·7 o 5·3) −8·9% (−12·5 o −6·1) −2·2% (−3·8 o −0·6) Mau i ius 66·8 (56·8 o 79·1) 55·9 (47·8 o 65·8) 43·7 (34·4 o 54·7) 15 (13 o 18) 10 (8 o 12) 6 (5 o 8) −1·4% (−3·0 o 0·4) −2·5% (−5·1 o 0·0) −1·9% (−3·0 o −0·6) Mozambique 363·4 (262·6 o 463·2) 250·0 (184·3 o 322·0) 248·7 (151·4 o 365·4) 2190 (1583 o 2791) 2339 (1724 o 3012) 2574 (1567 o 3783) −2·9% (−5·7 o 0·2) −0·2% (−3·9 o 3·0) −1·7% (−4·0 o 0·5) Rwanda 656·1 (528·6 o 791·5) 612·6 (477·4 o 766·5) 291·0 (189·9 o 400·7) 2021 (1628 o 2438) 2142 (1669 o 2680) 1185 (773 o 1631) −0·5% (−2·6 o 1·6) −7·6% (−11·6 o −4·0) −3·6% (−5·6 o −1·9) Seychelles 21·2 (16·4 o 26·7) 14·9 (11·6 o 18·9) 15·7 (12·2 o 20·7) 0 (0 o 0) 0 (0 o 0) 0 (0 o 0) −2·7% (−5·0 o −0·2) 0·5% (−2·8 o 4·0) −1·3% (−2·8 o 0·3) Somalia 486·9 (276·2 o 766·6) 422·4 (264·4 o 706·2) 407·7 (247·4 o 684·2) 1574 (893 o 2479) 1673 (1047 o 2797) 1903 (1155 o 3194) −1·1% (−4·2 o 1·9) −0·4% (−3·5 o 2·9) −0·8% (−2·8 o 1·6) Sou h Sudan 763·8 (432·8 o 1129·7) 872·9 (602·8 o 1172·3) 956·8 (685·1 o 1262·8) 2138 (1211 o 3162) 2718 (1877 o 3650) 3912 (2801 o 5163) 1·2% (−2·3 o 4·9) 0·9% (−2·5 o 4·8) 1·1% (−1·2 o 3·8) Lance . Au ho manusc ip ; a ailable in PMC 2014 Decembe 04.